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It <br /> SAN JOA.QUINCOUNTY ENI VIRONIME1 TAL IiLALTIi DEPARTMENT <br /> MAcTERFILE RECORD INFORIIIATION F0101 <br /> KhIesv Eli Program at Existia�Facility _ ❑Ncv;E11 ['rogram and I:css Facility_ <br /> IFacilit ID �a I'rraru Record I1�-EJS� <br /> Facility Address 256) -n anx — <br /> (Please Check the appropriate description and specify ave,numl er of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Pendia;Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Markel only ❑ t,fultiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Pellicle--Make Vehicle Type Color <br /> Registration# License# Slicker# <br /> ❑ Mobile Food Prep Unit—Mahe Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Eveat —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispeoser--Numbcr of Container in Nlulti-Iiead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) � <br /> ❑ hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle J Esempt System(2299) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered I'erinitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pen it-By-Rule Fixed Unit ❑ Pemut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and F forms- <br /> HOUSING <br /> orasHOUSING PROGRAM(2400) <br /> ❑ Hotenlotei Number of Units ❑ Jail or Exempt Institution--Numbcr of Units <br /> Employee Iiousing(2700)Use l:rplopec IfousirrKgbor Camp Applicariar Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ En`7roameatal Assessment ❑ UST-CAI'Site ❑ Local IM Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HAY Site ❑ non-NPLJSEP Cleanup Site ❑R)N'QCB Cleanup Site ❑ NNIater Quality Remedi:tion Site <br /> RECREATIOt4AL"EALTH PROGRAM(3600) <br /> ?dumber of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Sers'ice PoolJSpa ❑ Natural Bathing Arca <br /> VI=CTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING,PERMANENT_COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant. ❑ Clicmical Toilets Number of UniLs <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery«'asfc Site ❑ Sludge/Ash Site <br /> Kwaste'rire Facility ❑ Compost Facility ❑ Pro c ess(Re cycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu)'d—Number of Units ❑ FarnV-P?ach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursiag ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---❑ .2- 10---❑ 11 -60--- ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAra(4600) Uscf'IfsFfffl I6-02-003 fifrtr.Appliiariorr form <br /> EMERGENCY NOTIFiCAT1011 FOR Tills FACILITY ted` AND/OR PROGRAPA <br /> CONTACT rFRSON Day Ph Night PI, <br /> PROGRAM l,LFf\tEI ZT 4 7 Y O FEE ---- � T ❑ Surcharge FL-F ❑ C1thee F E <br /> Ir4srrcTotc,1 a6a0 PHM111''VAL.11) _ to ❑ Food ifandler <br /> ❑ Ch••rt.i1_ 1Rio1;,1r d1,ttrt _— -- r�atc_ --- ' lrr;tlh'F i1 <br /> ❑ r=a1h 1!e'.'!c";rDtt',' !'rr�•lq:PIt;QFr!,:E •I%�✓ l-j,i �1. �� — -- <br />