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V *3/02/2009 18:00 12098045 THE UPS STORES PAGE 03/04 <br /> S&N JQ.QUIN COUNTY ENVIRONMENTAL HEALTH MARTn ENT <br /> MASTERM. E,RE CORD-I;NFORMATI;ON FORM <br /> 0 New Ell ProoM Pro, at EXISOUg FRdrl E3Ncw.EH Prom and New Facility <br /> Facilit lA Fro ram Record TDFR DS3Dle leµ -P� /02� <br /> Facility Address f ZZ -I0_t� m ea <br /> (Please heck the appropriate descriptlou acrd specify size,number of units and pertineut info anon.) <br /> FOog 1 FgOG tAM(1600) <br /> L3 Restaurant: Stating Capacity Square Footage Food Handlers Course required-, Yks No Cl <br /> ❑Commissary ©Dry storage only ❑with Food Preparation [11'entdlag M2e3tines—Number of Units-- <br /> ❑Retalt Market----Square footage ❑with,Meat Market only ©Multiple Depart7zrertts 0 prepackaged Goods Only <br /> ©Mobile Food Vehicle---Make _ Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Vait-Make Vcl"icleTypc Color <br /> Registration 0 _ T^^ Licctuo# . . Sticker# <br /> ❑Temporary Food Facility----Dates of operation from to Ice Pia it <br /> ❑Special Event --Dates of operation from to - 13 Produce Stand <br /> bA1RY PROGRAM(2000) <br /> ❑Grade A Dalry E3 Grade A])airy ❑Milk Dispenser—Number of Containers in Mufti-Head Unit <br /> CVRA ❑state Facility Surcharge(2399) <br /> I1AZARDOUS WASTE PROGRAM(2200): P <br /> ❑Hazardous Waste Gencratar- ----•---Tons G=exited Per Year 13 Rocycle f Exempt System(2299) <br /> ❑CRT Offsite Handlers(2219) L3 Silver Only(2222) ❑Appliance Recyclers(221 7) <br /> Tiered Permitting Facility0 Conditionally Authodwd(CA) CI Conditionally Exempt(CE) <br /> D Petrait-$y-Rule Fixed Unit ❑permit By Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TAMC IwACXIGIfX'1f(AST)(2390) Number of,AST <br /> WMERGROUND STORAGE TANK(USI)PROGRAM(2300)Use Bgra4 and A tarnrs <br /> HOUSING PROGRAM(2400) <br /> Cl Rotcl/Mot e1------Number of Units .❑rail or Exempt Institution- --Nut%ta of El04 <br /> EcnployeeHmsing(2700)Usetamp.tnalim ort Form <br /> SITE MITIGATION(2900) UNbERG. 4UN0 IN.lEGT10NY CUHTR0L(3000) <br /> ❑Environmental Assessment 13 UST-CAP Site El Local RW Cleanup Site, D NPLISEP Cleanup Site ❑MC Site <br /> U Abandoned HW Site Q non-NPLOSEP Cleanup Site ❑RWQCB Cleanup Site ❑hYster Quality Remediation Site <br /> RECREAT10NAL HEALTH PROGRAM(3600) <br /> Nwtber of PoalstSpw at Facility. ❑Pool ❑Spa L3 Out of Service PooWSpa E3 Natural Bathing Arent <br /> VIED CONTROL P1it7GRAM(4000) <br /> ❑Poultry Fa;inY-•--•-"maxinwm nuaAa of birds ❑xennel <br /> 11raTull <br /> 00 0 ERCING tERMANENT C05METIC PROGRAM(4100) <br /> ttooiug(4121) E3Body Piorcing(4120) 13]Permanent Cosmetics(4122) <br /> D WASTE PROGRIEf M(4200) <br /> D]PumperWhielG Regishation# I,iccnselF Capacity Vehicle"#E <br /> 13 Pumper Yard ❑raelcage Treatment Plant, 13 Chemleal Toilets--__ Number of Units <br /> SOLID ViASTE P OGIRAM(440 <br /> ❑Landfill L3 Transfer Station 0 Ag f Cannery Waste Site 13 MudgefAslr Site <br /> Cl Waste Tire Facility E3com'post Facility L3rrocessmecycle Facility C]CIAundGtl Site <br /> 17 Refuse VeLtcles Number of Units ❑Dumpsfers>20 eu yd Number ofUnits_ ❑FarndRaneh Clc2vvp Site <br /> MEDICAL WASTE J 1KO.GRAM(4$00) <br /> U Primary Circ L3 Aeate Care El Skllled'Nursiag L3 Large Generator ❑Small Generator El Limned Ilauter <br /> ❑Transfer Station ❑Veterinary Clib is ❑Common Storage Facility-­U 2-10----❑ ]i-GO------L3}oo generators <br /> PUBLIC WATT=Ii SYSTEM PROGRAM(4600)Usea'K_'SSKA45-02-403 J_�3fr�e�fnnficafRon Form <br /> EMERGENCY NOVIFICATtON FOR THIS 1rACILITY ANNOR PROGRAM <br /> CONTACT I'ERSgm_-_A L( .r? IJay Ph Night PODO <br /> I'RUGRAMELEMENT FGE ❑Surcharge FEE ©Qtlacc DIFF, <br /> ]NsrucToR9 PERWTVALID . to ❑Vood Handler <br /> L3 Cr,eck# AMOUNT rA,ID Date INVOICE# <br /> 0 Cash REYIEWE5By AccovU t7Na OFFxF„ Date D Q <br />