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'All -?OAQUIN COUNTY ENW RONl, ENTAL HE LT11 DEP RTfVJENT <br /> _ M STERFIL1E R_ECOItD INFOMi IATION F0101 _ <br /> ❑New Eli I'rogrnat Exis(inr Facility _ _ ANcw fill I'rorram an_d 1 vi, Facility <br /> I+ _ <br /> acility 1-1) -AO��Lt,--; — I'rorram Rccord IID Q-0`S35� � <br /> Facility address AJAOLn �-�,� <br /> (Please Check the appropriate descriptioa and specify Eve,number of u its and pertinent information.) <br /> FOOD PROGRAM(IG04) <br /> ❑Restaurant: Seating Capacity Square Footage hood Handlers Course required: YEs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ wi(li Food Preparation ❑fending Machiacs-Number of Units <br /> ❑ Retail I1lat-ket—Squarc footage ❑ witli Met Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--flake /chicle Type Color <br /> Registration# License r: Sticker# <br /> ❑ Mobile Food Prep Unit-Mak-e Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dales of operation from to ❑ Ice I'laut <br /> ❑ Special Event -Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Pdilk Dispeuser--Number of Containers in Multi-Bead Unit <br /> COPA ❑ Slate Facility Surcharge(2399) <br /> IIA71RDOUS N5'ASTE PROGI-WN1(2200) t <br /> ❑ Hazardous Waste Generator-- "Pons Generated Per Year ❑ Zccycic I Exempt Sysicrn(2299) <br /> ❑ CRT Offsite I13-idlers (2218) ❑ Silver Only(2222) = L7 Appliance Recyclers(2217) <br /> Tiered Permitting:Fi+acilio, ❑ Coaditioually Authorized(CA) ❑ Coadition311y Exempt(CE) <br /> ❑Perruit-By-Rule Fixed Unit ❑ Pcinut-By-Mule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TA NIS_>i�A.0 LITY(AST)(2390) Numbcr of AST <br /> UNDERGROU-ND S T ORAC'E TANK K(UST)PROGRAM(2300)Use UST A artd B rarrrrs <br /> HOUSING PROGRAM(2400) <br /> ❑ IIotentotel Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> Prieployce housing(2700) Usc.Ftapfay c Housirzfl abor Carne Appficaliorc f om, <br /> SITE WIFT'IGC T ION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EaAronmcntal Assessruent ❑ UST-CAI*Site ❑ Local 11-4�'Cleanup Site ❑ NPLISEP Cleanup Site ❑ IJIC site <br /> ❑ Abaudoued HAY Site ❑ non-NPL<SEP Cleanup Site ❑ RwQc-B Cleanup Site ❑ 1�'ater Quality Remedi:ition Site. <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number ofPoels/Spas at Facility ❑ fool ❑ Spa ❑ Ou(of Sertiice rool/Spa ❑ Natural Bathing Arca <br /> EJECTOR CON T R-OL PROGRAM(4000) <br /> ❑ Poultry Farm l\faximum number of birds ❑ Kennel <br /> TATTOO, BODY MERGING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Ta(tooing(4121) ❑ Ilody Piercing(4120) ❑ I ermauent Cosmetics(4122) <br /> LIQUID WASTE PROGtzAPA(4200) <br /> I'uniper iTelaic le-I cgistrtion License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ I'acic3gc Treatment Plan( ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag(Cannery Waste Site ❑ Sludge/.ksh Site <br /> ��3'asic'Iire Facility ❑ Compost Facility ❑ I'rocess[Recycle Facility ❑ CIA,Laadfili Site <br /> ❑ Refuse Vehicles-Numbcr of Units - ❑ Dumpsters>20 cu yd —1lumber of Units ❑ FarnJl2snch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ NimaFy Care ❑ Acute Carc ❑ Skillcd Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary t=unic ❑ Corun.ion S(orage F::cility----❑ 2- 10---❑ 11 -60 -- ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRF M(4600) (lsc F'FINF11!1 /4-02-003 Rlrrc Alipficarion'Lwru <br /> iEr;lcr,fc-uttcy HOTtFICATIo;a FOR Tltis FACILITY ANDIOR PROGRAM <br /> C0I11TACI'PERSON Day Ph Night Ph <br /> FROGFAtM1,LFNFENT 4/7'/0 r,c:,: _-- 0 Surcharge 17E'E -- ❑ Coto FEE ---- - - <br /> Ir+srrcrat. PFI-U..HT',"ykLtD to ❑ Food handler <br /> ❑ �liccl. �.1,ihi�il? s ,airy Date- lt-IVC>Ir'L-r1 <br /> -- -- ------- — - - <br />