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P%J <br /> E iT <br /> SA-11 JOA-10UHN COUNTY HEAL DEP ARTM <br /> h�ASTl;R it R FC01 <br /> RDI ENTOMIATION FORM <br /> HIH ProLTarnj.d NewFacility <br /> ElNcw: <br /> • 2�Ne%v BH Progra"IM Exis(i <br /> DPAO <br /> A Pro riniecordi <br /> -Rl) <br /> Facility ID <br /> A-A <br /> F acility A-ddress <br /> (Please Check the appropriate des I criptioa and specify size,number of emits and pertinent information.) <br /> FOOD PROG13AM(160*0) Food Handlers Course required: YE:s El No- El <br /> El Restaurant: SeatingCapacitySquarr-Footage <br /> ElCommissary El Dry storage only 0 vith Food Preparation ElVending TA,-Achiaes-Number of Units <br /> E] Retail Il1-qrtcet—Square footage 11 with Meat Market only FI Multiple Departments El Prepackaged Goods Only <br /> [I 1\10bile Food Vellicle--flake Vehicle Type Color <br /> Registration q License ff Sticker# <br /> [I IlIobile Food Prep Unit-Mahe Vehicle Type Color <br /> Registration N License ft Sticker ft <br /> El Temporary Food Facility—Dates of operation frona— to EJ ice Plant <br /> FJ Special Event --Dates--Datesof operation from to El Produce Stand <br /> DXRY PROGRAM(2000) <br /> El Grade A Dairy, El Grade B Dairy ❑A.Tilk Disp­easer—Number of Containers in Multi-114-tad Unit <br /> CUpli 0 state.Facility Surcharge(2399) <br /> ISA 7 <br /> _,ARDOUS,"IAS 1 E PROGRA1\1(2200) <br /> [I 11azardous Waste C-c-nerafor—Tons Geacrated Per Year V,Recycle I Elempt System(229 9) <br /> 0 ORT Offsite Handlers(2218) El Silver Only(2222) FI Appliance R-ecyders(2217) <br /> Tiered re-rmiffing Facility 11 Conditioaally Auth-orizzed(CA) 0 Coadidona)Ily Exempt(CE) <br /> El Permit-lay-Rule F-ixed Uait [I remit-3y-Rule HouseLlold Hazardous Waste <br /> • 0 ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> --NDERC-ROU7`T10STO-L2--4GE'ifA-IqK(CJS T)PROGR"�,NI(2300)Use USFA mad fo,rvfs <br /> 2-JOUSiNG PROGRAM(2400)❑ 0 jail Or Ey its <br /> flotenjotel—Nurnber of Units _empt Institution,—Nurnbcro[Uni <br /> Employre lfousir,�(2700)Use E-r-,q7I <br /> SITE 6 t1-i MAT 90M(2W0) UNDERGROUND 9PTJOH COHTE0L(3000) <br /> ❑ Eavirop-meatal Assessment 0 UST-CAP Site 11 Local HW Cleanup Site. 0 NrLISE?Cleanup Site 11 UIC site <br /> ❑ Iibaudop-ed III'VV Site 11 Cleanup Site D a,%VQCB Cleanup Site I�Ipter Quality Remediation Site <br /> RECREAMNAL HEAUM PROGRAM(300) <br /> Number of Pools/Spas at Facility_ 11 pool 0 spa Out of S cnice Poouspa [I Natural B athiag'Area <br /> VEG-TOR.C-OMTCOOL PROGRAM(40010) 11 Kennel <br /> 0 Poultry Farm Maximum number of birds <br /> -rI/%-F- -OSME- <br /> p goo.BODY PJERCMG, PERNIAMEMT 6- o 9C PROGRAM(4100) <br /> El Matto oing(4 12 1) El Body Piercing(4120) [1 remaneat Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) Vehicle❑ ptimper VeTaicic-Registrationff License:f Capacity — <br /> P,Limper yard El Package Treatuicat Plant El CLernic-A Toilets—Number of Units <br /> SOLID'IASTF-PROGRAM(4400) El Slud-e/Ash Site <br /> 0 Landfill 0 Troasfer Station 0 Ag I Cannery V,'Rste Site <br /> KVVaste Tire Facility El Compost Facility 11 Facility El CIA L2ndfitl Site <br /> [I refuse VeLicles-Number of Units 0 Dumpsters>20 cu yd—Number of Units— El FaraVRnacli Cleanup Site <br /> MEDICAL VIAS YE PROGRAM(4500) <br /> El Primary Care- Acute Care 11 Skilled NursiaL- D Large Generator 0 Small Generator El Limited Hauler <br /> 0 Tr,-1asfcrStation 01 Vc-(c r i un rf C i i a i c FA Common-storage 2-10--E] 11 -60--El >60 generators <br /> PUBLIC;VTATER SYSTEM PROGRAM(4600) Uscl,[FSFWD;�6-02-003 RIttrApfilicatioa 1-70 1711 <br /> EMERGF-1-4CY FIOT5RCATIOH FOR-,ms FACILITY AND(OR PROGRAVi <br /> CONTACT PERSOIN Da",Ph Night Ph <br /> Pr,(:)GJukNI ELE MENT 75/0 Fir Ej Surcharges EE El Other FIEF <br /> I,NsrECT0R# (:96iJIV - F[-T,-N[ITVALID to 0 -Food Kfandlcr- <br /> ❑ Check s` AmOUNT I'AHJI D ate 114voICE"i — <br /> P—EVI D BY -U- a­-7 00 <br /> AccoU�!TII�13 OFFICE Da(c <br />