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HEALTH <br />New EH3rovram at Existin-E Facility (O i v� ❑New EH Program and New Facility <br />Facility ID Pro Record ID <br />Facility. ddress Lr,� A' <br />(Please Chem the appropriate description and specify size' number of units and pertinent information.) <br />FOOD PR GRAM(1600) <br />❑ Restaur t: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commis ary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units <br />❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -----Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile I Deal Prep Unit --Make Vehicle Type Calor <br />Registration # License # Sticker # <br />❑ Tempor ry Food Facility -----Dates of operation from to ❑ Ice Plant <br />❑ Special I vent --Dates of operation from to ❑ Produce Stand <br />DAIRY PR IGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />H Z OUS WASTE PROGRAM (2200) .I� <br />azardous Waste Generator ------------Tons Generated Per Year A ❑Recycle /Exempt System (2299) <br />RT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tie ed Permitting Facility------------ ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />UN ERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms <br />HOUSING ROGRAM (2400) <br />❑ Hotel/M tel -------Number of Units ❑ Jailor Exempt Institution -------Number of Units <br />Employee Ho ising (2700) Use Employee Housing/Labor Como Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environ nental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandot ed HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATI NAL HEALTH PROGRAM (3600) <br />Number of P ols/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR C DNTROL PROGRAM (4000) <br />❑ Poultry arm ---Maximum number of birds ❑ Kennel <br />TATTOO ODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooin (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />❑ Pumper <br />ehicle--Registration# License# Capacity <br />Vehicle# <br />❑ Pumper <br />and ❑ Package Treatment Plant ❑ Chemical Toilets -------Number <br />of Units <br />SOLID WASTE <br />PROGRAM (4400) <br />❑ Landfill <br />❑ Transfer.Station ❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste TI <br />re Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse <br />hicies --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units <br />❑ Farm/RaDch Cleanup Site <br />MEDICAL <br />ASTE PROGRAM (4500) <br />Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Primary <br />❑ Transfer <br />Station ❑ Veterinary Clinic ❑ Common Storage Facility ----- 112-10 ------- <br />❑ 11-60 ------❑ > 60 generators <br />PUBLIC <br />LTER SYSTEM PROGRAM (4600) Use PWSEHD 46-02-003 BlaeApplication Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT <br />PERSON Day Ph <br />Night Ph <br />PROGRAM <br />n <br />ELEMENT 111' FEE ❑ Surcharge FEE <br />❑ Other FEE <br />INSPECTOR t <br />PERMIT VALID (o -l-107 to 11L -4.,j -1D") <br />❑Food Handler <br />❑ Check # <br />AMOUNT PAID Date <br />INVOICE # <br />❑ Cash <br />REVIEWED BY W-146) ACCOUNTING OFFICE <br />Date 7 (/ <br />48-02-034 <br />Masterfile Record Pink <br />10/6/2003 <br />