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Am. dM <br /> P MASTERFILE RECORD INFORMATION FORM I <br /> RECEIVED <br /> O New EH Program at Existing Facility E]New EH Program and New FacilityFac~l.tyAddress <br /> (Please check the appropriate description and specify size,number of units and ENVIRONMENTAPERM[�S —�'—^~'' <br /> VICES <br /> FOOD PROGRAM(18O8) <br /> El Restaurant: SoatingCapauity____ Square Footage Food Handlers Course required: YES No [] <br /> [] Commissary [] Dry storage only [] with Food Preparation []VondingMachines Number ofUnits <br /> ________ <br /> [] Rmtai| K8arknt----Square footage [Iwith Meat Market only [] K8u|tip|eDeportments[] Prepackaged Goods Only <br /> [] Mobile Food Vehicle—K1eke Vehicle Type Color <br /> Registration# Lioenxe# GUnker# <br /> [] Mobile Food Prep Unit Make Vehicle Type Color <br /> Registration# Liuonoo# Stiukar# <br /> [] Temporary Food Facility—Dat000foperation from to Ice Plant <br /> [] Special Event Dates ofoperation from to [] Produce Stand <br /> DAIRY PROGRAM(u»»») <br /> [] Grade ADairy [] Grade 8Dairy [] Milk Dispenser-Number ofContainers inMulti-Head Unit <br /> ____ <br /> CLIPA <br /> [] Hazardous Materials Business Plan(1900) <br /> [] Co|ARPPnognom [] Program Facility [] Program 2Facility [] Program Facility <br /> [] Hazardous Waste Generator(22OO)----------> Tons Generated Per Year <br /> [] Tiered Permitting Facility-------/ [] CA(2232) [] CE (2233.2234. 2235. 2237) [] PBR(2231) [] P8RHHVV(u23V) <br /> [] Aboveground Storage Tank Facility(A8T) (28OO) Number ofASTo________ <br /> [] Underground Storage Tank Program (UST)(23UU) Use UST A and B forms <br /> [] Other CUPAProgram <br /> HOUSING PROGRAM(24O0) <br /> [] Hotel/Motel------Number ofUnits [] Jail orExempt Institution----Number ofUnits <br /> _________ <br /> Employee Housing(27OO) Use Employee HousinqlLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> [] Environmental Assessment [] UST-CAP Site [] Local HVVCleanup Site [] NPL/SEP Cleanup Site [] U|CSite <br /> [] Abandoned HVVSite [] nun-0PUSEPCleanup Site [] RVVQCBCleanup Site [] Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(30OO) <br /> Number ofPools/Spas utFacility [] Pool [] Spa [] Out ofService Pool/Spa [] Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4OUU) <br /> [] Pou|tryFarm---'Maximumnumberofbinda [] Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> 0Body Art Practitioner Reg (411O) [] Mechanical DSPSNotification (4115) [] Body Art Facility-Single Use(412O) <br /> [] Body Art Facility-Sterilization (4121) [] Body Art Temp Event Co'ond (4130) [] Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM 00) <br /> [] Pumper Vohiu|eRegiotmdon Lioonxa# Capacity Vehida#_______ <br /> [] Pumper Yard [] Package Treatment Plant [] Chemical Toilets----Number ofUnits <br /> SOLID WASTE PROGRAM(4400) <br /> El 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 I#mUnits) [] Dumpatom>2Ocuyd (#mUnits) [] 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' 18 [] 11 'O0 [] >8Ugenerators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> PROGRAM ELEMENTZillf") FEE El Surcharge FEE El Other FEE <br /> INSPECTOR# 0" PERMIT VALID to El Food Handier <br /> 11 Check# AMOUNT PAID <br /> Date INVOICE# <br /> 11 Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 48-02'034 MAorsnp/LsRECORD INFORMATION PINK <br />