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:/21/2021 10 : 39 PM FROM : Staples TO: +12094680333 P. 2 <br /> z 4� lir--T EPA HENT 'qYM <br /> 3L iEi4LTH <br /> p <br /> New EH Program at Existing Facili _ ❑New EH Proram and New Facil(tr APR 2 2021 <br /> - 1 <br /> Facilit iu �� I'ro ram ttecorYi_{u.__ SANdOq <br /> Facility Aaaress X2.2 � . ,�llYUnCr L(�U^( 1 nt.77� Wo�m <br /> (Plpaaa .hPf IC th,-,qn rnrlri;;ta ri,-gf-intfnn$nrf gnanifv ci7a nctrrrhar of r rrrita And nein rrtinfnnRSt70rr.) IV1E t G <br /> FOOD PROGRAM(1600) - - --- - -- - - -- � <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Fond Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footage ❑ w/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 ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event-Dates of operation frolic is ❑ CFO ❑ A ❑ o <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business Pian (1900) Number of chemicals: <br /> ❑ Ca(ARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)->-Tons Generated Per Year <br /> ❑ Tiered Permitting Facility------> ❑ CA(2232) ❑ CE(2233, 2234, 2235,2237) ❑ PBR(2231) ❑ PBR HHW (2236) <br /> ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program(UST)(2300) Use LISTA and S forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM (2400) <br /> 11 Hotel/Motel---Number of Units ❑ Jail or Exempt Institution---Number of Units <br /> Employee Housing(2700) Use Employee Housing Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ LIST-CAP Site ❑ Local HW Cleanup Site ❑ NPL1SEP Cleanup Sif- ❑ WC Sita <br /> ❑ Abandoned HW Site ❑ norr-N PUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ irve icf utiiaii y r�ctiiauic?tivei elite <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pooilspa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(?1 nn) <br /> Body Art Pracr;tioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facllity-Single Use(.4120) <br /> �❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse V4--hicles (#of units) ❑ Dumpsters>20 cu yd (#of units) ❑ Fa3rn,/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAilti(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing. ❑ Large Generator ❑ Small Generator ❑ Limiters Hauler <br /> u Transfer Station onVC;-urlrrarq,Clinic ❑ GamroT . -nn - an n cn.....,.....r,.... <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use Ptd 040 46-02-003 <br /> EmERGEr CYNOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> PEF;SOf,I ` ._ Day Ph 20Night Ph �Q 1( ] �"q- <br /> PROGRAM ELEMENT 4110 FEE S Z ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to 6/30f i ❑ Food Ra.tdle.�c-� <br /> ❑ ChPrk# Vi y,_ AmoiINT PAin #-Jam,da f)atP c�/Z1 2- INvrnr.F# 35-33Z <br />