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❑ New EH Program at Existing Facilitv ew EH Progan,and New Facility <br /> Facility ID rti'1 G 0 /-5 %I Program Record ID S33 2-77tr <br /> Facility Address f5 yv /u, Cr I �# 1 S�- C,4 95720 Z <br /> (Please Check the appropriate description and specify size number of units and pertinent information.) <br /> FOOD PROGRAM(1600) - <br /> ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YFs El NO ❑ <br /> El Commissary ❑ Dry storage only 11 with Food Preparation ❑Vendi¢g itilach fines-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 - ❑ Ice Plant <br /> ❑ Special Event - Datesofoperation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) - <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Ylilk Dispeaser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(23 - O G S�o><o <br /> HAZARDOUS WASTE PRO GRA t(2200) 2 7- <br /> ❑ Hazardous Waste Genera ---------- ----Tons Generated Per Year <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 USTA and B farms - <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteVMotel-------Number of Units ❑Jail or Exempt Institution—Number of Units - - <br /> Employee Housing(2700) Use Employee Hcu.tine/Lahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UiC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool Cl Spa Cl Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) - <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <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 Vehicles-Number of Units ❑ Dumpsters>20 to yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑Small Generator ❑ Limited Hauler, <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2-10—❑ 11 -60—❑>60 generators - <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Farm - <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph - <br /> PROGRAMELEMENT 22-70 FEE SurchargeEsy ' ❑ OtherFEE <br /> - <br /> IvSPECTOR# 3 3 PERMIT VALID J O to ❑.Foo d Handler." <br /> ❑ Check# AMO[MPAED t -).i, 2 - Date - - INVOICE# <br /> .- . _ <br /> ❑ cash REvmvEDBy AccommNGOPFICE Date U. <br /> Rcv-07/07199 <br /> EH 0069 PINK FORM.doc - - � - - _. .. - <br />