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May. 1. 2407 4:42PM UPiIT-ED SITE SERVICES <br /> _ No, 9130 P. 1 <br /> 7SAN 54AQUXN CO[)rY ENVMONMENTAL IMALTH DUATLnSNT <br /> MAsrEPYRZ=On UMP.IYATION FORM <br /> 0 New Tsti tropm d Existing FaSE' New BH P and Neve ciGty <br /> FaCill ID rLoom Record TD r <br /> F-ae ity Address <br /> (pie=.Check the ap"dato description and gmdfy ft nnmberof aattswatts itad nertlawt information <br /> ' POGb PRWRAM(1604) <br /> d Restattrant Slating CapadtYi 5@uare Footage p`ood Uactdlers CottrreetL ,. Yss Q No D <br /> 0 Commissary ❑Dry gene only Q with Foal Prepamdan ❑Veadw.dlrlachices Nmbar of Units_ <br /> Q Retail mamet-=-Square footage ❑wgh Meat Marla oNy Q motipic Deparw=ts ❑Pr ged Ocods Orly <br /> El Mobile Food Vehicle---4fte Vehicia Type Color <br /> Registration# Lim se# Sticker# f <br /> ❑Mobac Food Prep Unit--Make Vvwcle Type Color <br /> Registration# Lieewe# . Stidcor# <br /> Q Tt"orary Food Faehtttx#—Dates of operatiou front 4o 13 Ice P1=t <br /> Q Spidd Event --Dates o€operz6on from to Q-PrWace Sgmd ; <br /> DA1K OGREI (M) <br /> Q Cr*de A Daky ❑G•rade B Dairy 0 Mille Dispenser-N=ta of Cwtaiaers In multi-Head Unit <br /> c.SPA Q State Facluty surcharge(2399) <br /> KAMDOUS WASTE PROGRAM moo) <br /> ❑H=rdous Wslste Generator. —Tour(ie=abad Pet Y= ❑Recyde[Exempt System(2299) <br /> Q CRT Offsite Handlers(2212) C3 Silva Maly(2=) ❑Appliance R cyclers(2117) <br /> 1 ier6d Peru kting FxeWtyO Condidoaaliy AuffiadW(GA) 0 Condi=a Y EXCEV4(CE) <br /> C3 Permit Bye Fuzed Unit 0 Permit-By-Rule Homahold Harte Waste <br /> s q ABOVEGROUND STORAM TANKFACIT,TTY(AST)(2394) Number ofAST <br /> -UNDERGROUND STORAGE.TANK(USI)PROGRAM(2300)Use MMA md B&W <br /> USING PROGRAM(2400) <br /> E3 HotditoW :umber o(Unift U Jaw or Exempt InsMution—Number of Units <br /> Pmptoy"x gmb g(27Db)Use F.nralvwee•Ho _ bor Gl my►tent,Fom <br /> SM MMGGATIOtf('2900) UNDERGROUND IUJEC130H 22k0301_,(3040) <br /> •❑Enviroms wtal Astaessment Q w-CAP Site ❑Local SW Cleanup Site. ❑NYLISEP C%=up Site ❑UIC ate <br /> 17 Abandvsied IEW Site 0 won-NPLISEP C1m%p M b RWQM C1almup Site 'E31V0Ar Quality Remediation Ste` <br /> Rt:CREA710NAL HE=At,.YH PROGRAM(36W) <br /> j: Nn itw ofPoolstspm at Fsdlity ❑?got ❑spa ❑Out of service Pooysprl El li mar:l Bathlo Area. <br /> VZ=CZ'OR GOMMOL PROGRAM(444 L� <br /> 13roult j Farm--- Dart nmim of birds Kesmlel <br /> PIERCIN0.Parrtirc CO•SMET1 RAM(4104) <br /> 0 Tatwdat(4121) Q Body Piercing(4120) ❑Prrmsacnt Cumeft(4122) <br />�. jjQUid WASTE PROG�N_(4200) <br /> ❑Pumper Vahhde�on# cva4ty__.. Yehsicle _ <br /> ❑Pumper Yard ©package Treatat:eat riasrt- K Cheudcah Toiicts—Nuvbw o£Uaits <br /> AMDWAM P!MQRAM(4400) <br /> L1 IMM ❑T<aasfer Station ❑Ag l Qmuery Wide Site ❑SludgeOAA Site <br /> 13 Waste Tire FRd ty ❑Compost Fpefty13 ProcasllZecycleFaell[ty 0 clArl.=ri t Site <br /> C3 Refasr Vdddcs Nnmbjr of Units___^_,•` ❑F +xx>20 eu Yd«—N=Aw of tJab ❑Farmmanch aewup Site <br /> MEDICAL WAM PROGRAM(4544) <br /> d PAmuT tyre ' Q Acute C*re C]SkMed'Nursing U Large Generator ❑Small Generator Q Limited Hauler <br /> 0 Transfer Station ❑Veterinary Qinte ❑Commos Storzge Fic,'lity-•�-•❑2-10-------E3 11•-60—[1>GO gwen tars <br /> PURLf C WATER SYSTem_PfipGRAM(4 6W)Usc ENT EHD 46-02-003 ,Blae.4PWa-ff1mn Form <br /> — F-MMOM4CJ Y NoTIFICATIDH ratt THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON ,Sy_�. l��f•k.��.ror�2. Day Ph <br /> S �s Night Pts <br /> PROGRAM ' ri BENT FEE L M&srcharge Fz ❑Otbor nE i <br /> InsP$crotZ _ 5",,l_4 q 1?1 1r VALtD; 1'1 i b'7 to at g[-Lo' C)Food Sandler r <br /> IQ?3i <br /> L7 cascck a AMOUNTFAM «�� �D Date�7 lVtd� Irtv0lcE# 1 <br /> 0 rAA P.EVf51l'EI?SY AcCDUKru�o 0F= � Date 671Jy 7 <br /> c <br />