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DocuSign Envelope ID: F8CF0021-0323-43B5-8B51-98760B92310D PA =-sari .�oA�ul�! courvTv Ery =_— RE Y�ENT VIROfVN(EP�TAL {HEALTH DEPAP,T�IEI�T CEj��® _ _ _ ll4ASTERFILE RECORD INFORIt!IATlON FORllrl ____ __ �� QPR ' 19 New EH Program at Existing Facility _ !L ❑New EH Program and New Facility S 0 2��g FacilityID � SZ!D Program Record ID �S �V/RQ MEwtV Facility Address 1 Z 1 S � � pgRr NTY �-� L� �t�� NTAL MFNT (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM,(1600) (1 Restaurant: Seating Capacity Square Footage F O Food Handlers Course required: YES NO ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make_ Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker it ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAf4(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Mill:Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP 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) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/fifiotel------Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housinu/Labor Camp Application Form SITE 10PTIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HkN Site ❑ non-NPL/SEP 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 VehicleRegistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd (#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form / EIAERGENcy NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON O (li �1 11� I7 �tYr�.i�f Day Ph 1 0)3 I�7 t light Ph i PROGRAM ELEMENT FEE S. •vJ ❑ SurchaV a FEE ❑ Other FEE INSPECTOR# PERMIT VALID t0 O ZO ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# �b ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date l 48-02-034 MASTERFILE RE RD FOR+IATION PINK 1/23/13