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N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ❑ New EH Program at Existing Facility New EH Program and New Facility Facility ID Program Record ID 11 Facility Address N��10 �t r� A1�� 1 )+eew . Cf� 4S 33l (Please check the appropriate description and specify size number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEsIE], No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Nu ber of Units ❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments.IJ Prepackaged Goods Only ❑ Mobile Food Vehicle -Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility -Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event ---Dates of operation from to , ErCFO JIA A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) ----->-Tons Generated Per Year ❑ Tiered Permitting Facility ----> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution --Number of Units Employee Housing (2700) Use Employee Housing/Labor Cama Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm --Maximum number of birds ❑ Kennel TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120 ❑ Body Art Facility -Sterilization (4121) [1 Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Eve4PAWEAilty (4131) LIQUID WASTE PROGRAM (4200) RECEIVED ❑ Pumper Vehicle Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of LMAR 0 Q 7023 SOLID WASTE PROGRAM (4400) N UNTY ❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ � IW 11Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility dgp/ W&AENT ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 011-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PROGRAMS INSPECTOR # ❑ Check #\_ ❑ Cash 4&02-034 1123113 Day Ph Ph ':09. �7- FEE I � �n ❑ Surcharge FEE ❑ Other FEE PERMIT VALID t0 AMOUNT PAID o Date REVIEWED BY • I ❑ Food Handler 2-2' INVOICE# Date J PINK S