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BAN .)OAQUIN COUNTY STERFILE RECORD NFORMAT oNF DEPARTMENT FORM MA &Kew EH Program at Existing Facility ❑New EH Program and New Facilit Facility ID 9Q222 2/ Program Record ID kos-+g Facility Address;� A r✓, LtA eytrvl-Ai- Lr\ ! ) -1 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage -�—Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ZkRetail Market---Square footage�3 000 ❑ w/Meat Market only ❑ Multiple Departments 0-Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event--Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit _ CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)--------->-Tons Generated Per Year ❑ Tiered Permitting Facility-----> ❑ CA(2232) ❑ CE (2233,2234,2235,2237) ❑ PBR(2231) ❑ PER HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program(UST) (2300) Use USTA and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) .. ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution---Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm----Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) P��r •' ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/may it0/►VN71 ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Lan �� /� ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd (#of units) ❑ Farm/ Cleanu�7te MEDICAL WASTE PROGRAM(4500) N / s �A �1�0 Y0Z3 ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generat4`tP "'"�fNd Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 HEA�p®��R�AktrWrys PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form ME lq EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM /— p CONTACT PERSON L Day Ph 20p1—I6Sf 3��Iight Ph ��—t�b 1 3� PROGRAM ELEMENT- FEE Y) ❑ Surcharge.FEE ❑ Other FEE INSPECTOR# _ PERMIT VALI t0 ❑ Food Handier 111Check# AMOUNT PAID Date INVOICE# .375 I 66 C h REVIEWED BY ACCOUNTING OFFICE Date 37Z/ 48-02'034 C l 5`1b�g��l�-V MASTERFILE RECORD INFORMATION PINK