Laserfiche WebLink
• • <br /> [!!!ft=RFILERECORI)INFORr4ATIONFIORIN1 <br /> TY ENVIRONNI,ENTAL HEALTH DEPARTMENT <br /> XNew EH Program at Existing Facility El New EH Program and New Facility <br /> Facilif ID 77Pro ramRecorrd.ID P� (o� <br /> Facility Address b°lti0 {)r> c' �-^7 fTt�C_ <br /> (Please Check the appropriate description and specify size•number oC units and eertinent information.} <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage food Handlers Course required:. Yrs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only Elwith Food Preparation IJVending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to 11 Ice Plant <br /> El special Event —Dates of operation from to [I Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑hazardous Waste Generator..= Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotei/15Iote1 Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Ifoasit lejTgbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local IHV Cleanup Site, ❑NPL/SEP Cleanup Site 11UIC Site <br /> ❑ Abandoned IiW Site ❑non-NPL;SEP Cleanup Site ❑R`VQCB Cleanup Site ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑Out of Service Pool[Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle—Registratioa# License# Capacity Vehicle.# <br /> ❑ Pumper Yard ❑Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ElTransfer Station 11 Ag l Cannery Waste Site ❑Sludge/Ash Site <br /> ❑ Waste Tire Facility 11 Compost Facility 11ProcesslRecycle Facility 11CIA•Landfili Site <br /> ®Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute CareSkilled"Nurs'mg ❑ Large Generator ® Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60--El>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePlf'SFHD46-02-403 BlueApplicadon Form <br /> EMERGENCY NOTIFICATION FOR THIs FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAAt ELEMENT —/So?'—' _ FEE YA '/DS r ❑SurchargeFFE-. ❑ Other FEE <br /> INSPFCroR# e' �-_ PERMIT VALID to 17-431111 ❑ Food Handler_ <br /> Check€ AnzOUNT P,e,ir) • _ 'Date INVOICE# ISI ._— <br /> k Cash KEVIEWED BY ACCOUNTING OFFICE _ _�— _Datta' <br />