|
,y ,. : ... .. ;t.:•: !lis ;.i{•:::j;;,^ }:u '•:.J.Yr;;R
<br /> ;ltic' r.a,r.--....,,..•._ ,.. •., .:,-v,.,•.. ?stt :,t ��a,}' ,��tt1.�'t's '11,..
<br /> J U fJ CGUl+�'i''r k'�VIRONMEN AL HEALTH DEPARTM.ENT.,':::`;'<: ' ;: `;' ; ;,,t.'•. r r�urr # �' :, �
<br /> OA4 ! T :,. ;y :f.:SF p� 1
<br /> ....:.. ..... .. .. ... ,..,...:...,::-......r•.�.
<br /> •.ii'isa`::''•••��'•'. �.;i\i�'t7..:•,`f1i.,,.;t:;:�:.•:.�_:,pi ;.(•: .i./ 'SX'r;E:v.
<br /> MASTEi1F;i,l:- RECORD INFORMATION FOR i;,;';b`>• ;::, `;', � '�v:'.
<br /> M.r._r.i—:.•^-e+-..m.wuas,,:�••n•,«..ter.;. _ _ _�'_ . is -
<br /> New EH Program ca EXIS�tt1C F:u:il,IylNew EH Pro ram and New_
<br /> Pro ram Record ID �:�:,•.;s. _.,,:,.:,,,
<br /> Facility ID ���i .Z • 9 �.:.':,.. ,
<br /> ..... .,
<br /> c :{ AddressZZNS �r�� S ��a C��1S'Zo
<br /> ,� pertinent'nformati on.
<br /> ease check the a Tro xiate loser Iia:1;n ands specify size number of units and pertine I �;
<br /> :.SPI ::..; p} i l p Y
<br /> 161:0
<br /> •OD PROGRAM
<br /> (
<br /> )
<br /> >y�r.
<br /> / l a e Food Handlers Course required:. '1!Es fl
<br /> `�Restaura Seatirkr;C<.pac:tl; _....... S:it are Foot g ;i
<br /> J Commissary Dry slor<;c-ort;' '..J with Food Preparation '.. . .•'❑Vendi:•g Machines Nu bar Pf.Units
<br /> ';D.Retall Market �u4le foo;ac;:a „_.•, O►n�/Meat Market only ❑Multiple Departments❑ Prepackaged Goods„Atlysx
<br /> .y,. . ?;;•i(::%a„ ry'''*'��, arse
<br /> 'i❑ Mobile Food VehicVehicle Type "' " Co1ar
<br /> Re•;lis:�tic'n;r^--._.......
<br /> 'License Sticker#. ,.i•..ST ;
<br /> ;❑ • _ ..._.. ..-- _ 'ColorMobile Food Prop U:r: Vehicle Type
<br /> r ;License# ::,';:•::. N r:�Yr)' rtr
<br /> .: 12rr I<•?r;:tic:l, 1 %:Sticker#,.
<br /> i'❑ TemporaryFood i'aciii.l L<' 'r:• :. '•:ti.ra;ie!t from ;to . "❑,Ice Plant O ProduccStan{ ^
<br /> 0
<br /> Special Event--l7:ttF:'of c}t}er,:!:.t ;'.-II'i to ::t. '..':.❑ CFO .�A 1],B77777
<br /> @N,r
<br /> , nr
<br /> tF:
<br /> Js
<br /> 'D Y
<br /> PROGRAM
<br /> C
<br /> :••tt
<br /> h
<br /> •5 Sr r
<br /> ' • -.••. • .• -Number o f.Containers C ontainers in Mutr-H ad
<br /> U.'
<br /> 'alt© Milkispenser❑ G �: yGade ADal ai
<br /> 5
<br /> �•��
<br /> ��.
<br /> Y
<br /> '.::;:•r�:...• <� +�_ �' ern
<br /> r'(!
<br /> x5•s
<br /> a
<br /> U •r+
<br /> Xl
<br /> r;k•: ,
<br /> ,y::•,
<br /> a
<br /> h '
<br /> Y. 'J
<br /> '�chemicals:
<br /> •
<br /> rs N •mbar f ch •a',k.,
<br /> �•M to r
<br /> ��:❑.Hazardous ,.,.
<br /> , )
<br /> Program Facitit
<br /> CaIARP.:Pro ram h. c):;ram 1 cility :b Program 2 Facility ..la] y ::::'^• :`?':'t .,'; ..:.t:H:J;. � `..r; ,
<br /> Q.Hazardous Waste L<:it.., -> To Generated Per Year ;.. ... ..:.::... ..::
<br /> c �;� '"'rJA(2232} CE(2233,2234,2235,2237). 'O PBR•(2231) .❑,ABR H,HW X2236 ; `;"
<br /> " 7 Tiered P.ermittinJ , _::li< )siwyy§r' r-r`
<br /> ^'1�.. • .,. � :i 15:i:i�Yi/'S'�'t�"'•,Y�4'Y,,"+'Sly?a
<br /> }' b o ve round Stca ac, 7 ll.;F'„,:1:: ST 'LS00'
<br /> umber of AS7s
<br /> f r s
<br /> A and B o m
<br /> T a .,1.
<br /> :t
<br /> , .JST x.300 Use H.:,,�•:-,
<br /> r:•c.4 ant •.a:.
<br /> nd Sto t
<br /> •de
<br /> rou ..�:•�
<br /> Un r t'
<br /> g �
<br /> >f:•L
<br /> +�.t
<br /> Other CUPA P
<br /> C! t
<br /> ::�:••::.
<br /> •xt.
<br /> •h.
<br /> :•1
<br /> ,a
<br /> �OUSING PROGR r9 + r.}
<br /> i •r,•:tki�n
<br /> 1 :I
<br /> <t r
<br /> y r
<br /> , rt
<br /> 1Exempt ��•�Of�U•.its••� .t
<br /> • e
<br /> ,••�
<br /> all or institution•---N ,.>r .<��i
<br /> .
<br /> ;•
<br /> _
<br /> 7
<br /> . • '
<br /> rmE )10
<br /> Employee Housing( n Ca ALica 7Fo
<br /> r
<br /> M:
<br /> R0.h.
<br /> M{TlGAT1 � •UNDERGON CONTROL(3000)0N(2JL0) ROUND INJEC
<br /> :;;.,,,;•�,�, �' ,
<br /> r` :j::--'%P
<br /> ••❑:Environmental AFsea:,rtter:; __.t ; Site ❑ Local HW Cleanup ite I]•NPLlSEP Cleanup Site:,,`:.'Cl;lJ,•, Site,,.
<br /> ❑Abandoned HW Zito "D :.... i':?USEP Cleanup Site ❑ RWQCB C anup Site: .'.Q WaterQuality Reme�latlon Sl . st:
<br /> a
<br /> I•
<br /> :�}ZEC t b
<br /> R TIONAL
<br /> IEAL', i^
<br /> � EA
<br /> ;.0 1
<br /> yrF.,
<br /> t a t ;c11:t` �7 Pool ❑ S a `:`❑Out of Se ice.Pool/Spa C]Natural,Bathings.,xreaw
<br /> ;iNumber of Pools/Sp< i ,_—_..__ !? :.y
<br /> t:
<br /> .•R f1r
<br /> ECTOR CONTROL
<br /> ;
<br /> .I
<br /> ..;r. a.
<br /> t�
<br /> :1
<br /> t I jT
<br /> a,Q Poultry.F.arm-----AJl�.amurtla'rrds a�;r>!;•a.
<br /> PlE CING PERM :.-r-;:-.19ETICPROGRAM (4100)..:TTOO. lN ::'.'. ::: i"'' :,.„-:',t.•ri.
<br /> : Ll Body Art PractitiorT;r!?ec} (A !}; t:J Mechanical DSPS Notification(4115) ❑ Sod A actltty-Stngie Use(4120) '
<br /> :4-',33 Bod Art Facility-$te:riIiz:iticr•• i•i^::'0:I ❑ Body Art Temp Event Co-Ord(4130) ,❑ Body Art- mp Event Mo 37�
<br /> tl UID WASTE PFO •,Fsi'n.;4200',
<br /> . . .
<br /> Pumper Vehicle C a `.;:!,alert; _..._�_— License# 'fBD OMv' :Capacity/ZOO Vehicle
<br /> ::❑ Pum er Yard511
<br /> -
<br /> p '.age Treatment Plant Chemical Toilets Units._ ���
<br /> � r
<br /> `.SOLID
<br /> WASTE PROG '•.4J t
<br /> it.
<br /> c
<br /> •,
<br /> i Waste Site ❑ Slue a/As .$ite' %i.,, :• „f,,
<br /> ❑A /Canna W st h,;..,:,:; }c.
<br /> Landfill 9 ry , �'��"=
<br /> :t ' Tire'' - , , = it Site. "-r fr�>st
<br /> : acilitr t7 Cor,t41:.:.. ...,,,r:' :❑ Process/Recycle Facility. .❑
<br /> CIA
<br /> c, Waste F , 1
<br /> u ❑ Dum stets>.20 Gu d rz of ugits) " ❑ Farm% rich,Cleanup`Sl u
<br /> .Refuse Vehicles k...il t:t':iI3)_,_• p y,.f % i
<br /> ..
<br /> ..,"•r. sir 4 Y�.
<br /> i
<br /> r�
<br /> rr.
<br /> r•nr < T
<br /> •T•
<br /> r~
<br /> t)
<br /> '1UIEDICAL WASTE PRC• l= t ;,_ ����,
<br /> :'O,Primary Care L Act:to Cct:'••r w:1 Stalled Nursing ❑ Large Generator I] Small Generator.❑ Limned Hauler ry?+€x
<br /> CI Transfer$tatian i[3 'Jeter'inz:r .c ❑ Common Storage Facillty -
<br /> ❑.2 ,10 1'1-..60. :'CI >..60.genere o # "
<br /> gJ, ft
<br /> n
<br /> t-:
<br /> 1' tlo Fp
<br /> nn.A o tca F rm
<br /> UBL1C WATER SYST:_^•.i.^:JGi:,=.r':, .._:i . ::e PWS EHD 46-02-003 D . .. ;:�•�iay+!�::,~*,,.<;
<br /> <, r•.:=r;uv NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM
<br /> OONTACT PERSOtJ �� /Yl�tl iC Day Ph ((Off?/3y7• /(O g : :•:.;.�(� 3/<i�f0%.(p: ';;<::K�: . r-h:
<br /> 7th( / Ni ht Ph ra?r
<br /> PROGRAM ELEMENT � :-_ ❑Surcharge FEE Other.FEEINSPECTOR
<br /> ..:...#. — �_. ... :to tl Food,Handler
<br /> Date `INVOICE#
<br /> •• .. .. .. ..... }'!?.ill!t!1,i'+.i
<br /> El Cash ,RfvlFt'•:I_!)7Y ACCOUNTING OFFICE bate
<br /> -_ --__.___'a_•...r.m•r.•_.- .r'--... ....-,.•..a. e7,awarr:.},
<br /> .''48-02-034 MASTERFILE RECORD INF.ORMATiON.P1N.KiF�+r
<br />
|