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Facility ID jam' 2-72-9). Pro ram record ID <br />pro <br />Facility' Address <br />(Please check the appropdato description and specify size, 4 ber of I,nits and Pertinent_— m� ) <br />( 1 YES <br />p�No ❑ <br />F ODP 16007�dis Course required: <br />Restaurant: Sealing Capacity_ Square Footage ❑Vending Machines Number of Units � <br />Commissary ❑ Dry storage only ❑ with Food Preparation Markel only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Retail Market --Square footage Color --� <br />❑ Mobile Food Vehicle --Make Vehicle Type Sticker If ---------- <br />Registration # License # Color ----------� <br />❑ Mobile Food Prep Unit- Make Vehicle Type Slicker Ifd <br />Registration # License #�— C] ice Plant 11Produce Stan <br />❑ Temporary Food Facility -Dates of operation from to � CFO ❑ A ❑ B <br />❑ Special Event --Dates of operation from to12 <br />�— <br />DAIRY PROGRAM (2000) <br />13 Grade A Dairy 11 Grade B Dairy [I Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Pian (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility El Program 2 Facility L] program 3 Facility <br />❑ Hazardous Waste Generator (2200) --->-Tons Generated Per Year2236) <br />❑ Tiered Permitting Facility —> ❑ CA (2232) [1 CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ P8R HHW <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee HousinglLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment 11UST-CAPSite ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service PooVSpa ❑Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) ❑ Kennel <br />❑ Poultry Farm --Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art FacilitySterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) Capacity -Vehicle # <br />❑ Pumper Vehicle Registration If License # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgelAsh Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ ProcessiRecycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ FarmfRanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑Skilled <br />C1 Primary Care ❑Acute Care Nursing 1:1 Large Generator ❑Small Generator ❑ Limited Hauler <br />❑ Common Storage Facility ❑ 2 -10 011-60 ❑ > 60 generators <br />❑ Transfer Station [I Veterinary Clinic <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form <br />IL--kJ�.� RGENCY N&IFICATION FOR THIS FAC IT AND/ R AM <br />CONTACT PERSON Day Ph Ight Ph <br />PROGRAM ELEMENT \<D. L FEE ��- ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # `1`I '�'/ e5 PERMIT VALID IGs ZZ - Z Z to �'_3 D— z3 ❑Food Handler <br />❑ Check If AMOUNT PAID 17 Date INVOICE # <br />❑ Cash REVIEWED BY ACC UNTING OFFICE Date Z� <br />NCnPUAT10N PINK <br />1123113 <br />