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RECD ,eD <br />SAN <br />JOAQUINN DEPARTMENT <br />?MASTWUfn.)I 533Iv/T <br />ERFILER CORD INFORMATION FORM 02 <br />InV <br />ONeEH P ON.EHPro edNeFpdWINJOq <br />QUINprage <br />t,VS P��MP0mo �pENM�N �Faility ddre0"� <br />(Please ro11eletlncrlansttenumber units <br />Fo00PRWA M(1600) �T <br />O Restaurant Seeing Capacity_ S9g{1��ere Footage Food Handlers Course reu red, Y.13Nov <br />�mmissory O Dry storage only 021, Food Preparation Mending Machines Number of Units_ <br />❑ Retail Market -square footage O wNessi Merkel onty O Multiple Departments O Prepackaged Goods Only <br />O Mobile Food Vehlcle-Make —verdeType Color <br />Registration# Ucense# Sticker* <br />O Mobile Food Prep Unit -Make Vehide Type Cola <br />Registration# license# Sticks# <br />O Temporary Food Facility -Dates of aperotinn from to D 1 Plant O Produce SMnd <br />O Speclol Event- Dstes of oparotlon ham to Q CFO A O B <br />DAIRY PROGRAM (2000) <br />O Grade A Dalry O Grade B Dalry 0 Milk Dispenser -Number of Containers In Multl-Heed Unit <br />CUPA <br />O Haaurdous Materials Business Plan (100) Number of tllemlcels: <br />D CaIARP Program 0 Program 1 Facility D Program 2 Facility 0 Program 3 Facility <br />D Hazardous Wane Generator (2200)—,Tons Generated PerYear <br />D Tered Permadng Faellky—> OCA(2232) OCE (2233.2234 2235.2237) D PBR (2231) D PSR HHia12236) <br />D Abovegmund Storage Tank Facility (AST)(2B00) Numberof AST; <br />O Underground Storage Tank Program (UST) (2300) Use LST A and B forms <br />D Other CUPA Program <br />HOUSING PROGRAM (2400) <br />O HotelRAotel—Number a Units O Jail or Exempt institution—Number of Units_ <br />Employee Houalne (2700) Use Camo Aoolicedon Form <br />SItEMMGATON(2900) UNDERGROUND INJECTION CONIROL(300D) <br />D Environmental Assessment 0 UST -CAP Site O Local HW Cleanup SIM O NPLISEP Cleanup Sib O UIC Sib <br />D Abandoned HW Site Ormrl-NPUSEPCIeanup SNe D RWOCB Cleanup Sift O Water Quality Remedlatlon Slte <br />RECREATIONAL HEALTH PROGRAM(36C0) <br />Number of PwI Spas W Fadllty _ O Pool O Spa 0 Out Of Service Poolmpa O Natural Berlin, Area <br />VECTOR CONTROL PROGRAM! (4000) <br />O Poultry Fann—Maximum number of birds O Kennel <br />4100) <br />OBody ArtPractllloner Reg(4110) OMtthanlcal DSPSNotMlcation(4115) O Body Art FacllltySingle Use (4120) <br />D Body Art Faellity-Shdlixa6on(4121) O Body Art Temp Event Co-ord(4130) 13Body Art -Temp Event Mobile Facility(4131) <br />LIQUID WASTE PROGRAM (4200) <br />OPumper VehicaReglstrallon# License# Cspa* Vehicle#_ <br />O Pumper Yard O Package Treatment Place OChemlael Tolleb—Numberof UnOs <br />SOLID WASTE PR WRAM (M00) <br />O Landfill O Transfer auction O AglCannery Waste Site O Vudg&Ash SIM <br />O Waste Tim Facility D Compost Facility D Proeesaxecycle Facility DCIA UndOil Site <br />D Refuse Vehicles Poruninl_ 13 Dumpstem > 20 our yd pnLwol_ O FarmlRanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />D Primary Care D Acute Care D Skilled Nursing O Large Generator D Small Generator D Um@ed Hauler <br />O Transfer Station O Vetednary Clinic O Common Storage Facility D 2-10 011-60 O>60 generators <br />CVBI1gJY (4600) Use PWS END 4642-003 Blue Application Farm <br />INEletRRa£N rams ONc IOUs,FACILJ l P �-y/)� <br />CONTACT PERSON I Q ~ I Day Ph ggIT <br />PROGRAM <br />IxsPecroax FEE 0SureMrge F. DOther FEE <br />PEAMITVAW 2.0— to 13 Food Han <br />dler <br />OINvoICELO Check xM AMT <br />Date <br />❑ cern Rmr. er 11 AccouxrlxG Ormce i Dale Z!/2- <br />� <br />