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Ski( J 0 A (J 1` C1;�Ii`,`K 1' 1; ,'.11`fJNF IF'M ,,VL 11EA `I s1 Vii; <br /> a <br /> i`it,S�I fL1+�I !"D_'t:71J)_41';i'01-'2J 6I0il FORM <br /> I�'1^, l✓l-1 I'Nfl:a�i 3l 1�:1 tStlLgixlftr,ty --,u =- -- Uicw -'l]_P,op-irn LrA Nelt_d_,ackicy <br /> ijacih0,1D FAOO1 �_ � 1",_�r,itt�Rccord ID <br /> ,,icihbyd—dr( Ss <br /> (pleasc Check-the aTproFriaie ties cri0tian._nd specify sib number of units and perfinent inrort��tion-J <br /> FOOD PROGRAM(1GOO) <br /> 1:11\'CstaUr3n(: Seating Capaci(y Square Footage food 9aartdlers COursG i equired: YES F1 NO <br /> El Commissary ❑ Dry storage only El Mill Food preparation ❑Vcadin;Machines -dumber of Uni(s <br /> ❑ I:ctail li'[art:e(--Square footage ❑ with 114cat tvlul"A only ❑ 1,lultiple Depalmcnts ❑ Prepackaged Goods Only <br /> ❑ Mobile Food tirchicdc — Prf l;e Vehicle T)Tc Colur <br /> Registration# License i, Sticker il <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> registration# Liccnse iy Sticker n <br /> Ela <br /> Tempos ry Food Facility---gates of operafclli <br /> tion to El ice Plant <br /> ❑ Spc-cia[Eveat --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Gra-de A Dairy' ❑ Grade B E c), er---14anIbcr of Containers in 1,iuiti-11ead Unit <br /> CUP'A ❑ State Facility Surcharge(2399) <br /> LL LAItDOUSWASTE PROGRAM(2200) ) <br /> ❑ 11a7.'rdous Write Generator-- Tors Generated Pcc Year ❑ [Zec)`cle/3 erur,(S)'sterri(2299) <br /> El CRT O#fsife Handlers(221€) ❑ Silver Only(2222) _ ❑ Appliance R'ecyclers(2217) <br /> Tiered 1'r_riui(tin ❑ Conditionally Authorized(CA) ❑ C�Inditioi,aliy i-::cmpt(CE) <br /> ❑ 1 cramit-By-R�ulc Fixed Unit ❑ I,.matt-fay l;ulc not-°chold Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK rACIL1TY(AST)(2390) Ilun-rbcr of AST <br /> LINDERGI.OUND S T OPUGE TA11K(UST)PR0-GILA M(2300) Usa U.STA and P��ar,rs <br /> HOUSING PROGRAM(2400) <br /> Hotelni loiel--Number of Units ❑ .l ai4 Apr 7E.Ceurp(rrstitrriio[r---llumb--r of Units <br /> Eraploy ee Ifo sing(2700) Use isncpfop« Camp I pplica(iort form <br /> SITE MITIGATION(2900) UNDERGROUND INJECT ION CONTROL0000) <br /> ❑ Euvironmcet_11 Assessment ❑ UST-CAP Site ❑ L oczl WN Cle�uup Sitc. ❑ NPIDSE1,Cl:_znupr Site 11 -Luc Site <br /> ❑ Abandoaed UM'Site ❑ non-Pie ISEP Cle:'aup Site ❑ 1'WQCB Cleanup Site ❑`;',later Q�u lity Remediation Site <br /> cZECREATIONAL HEALTH PROGRAM(3600) <br /> Plumber orpoolslSpas at facility ❑Pool ❑ Spa ❑ Out of Sc.vvicc PooUSra ❑ Natural Bathing Arta <br /> 'JEC T OR COHTROL PROGRAM(4000) <br /> ❑ Poultry Farm--nl`: <br />