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LTH <br /> � � �/ /SANJQA�UINA ENVIRONMENTAL � DEPARTAENTSTERFlEREo � FORMAT4NaRM <br /> L � � <br /> �O <br /> ew EH Progr�m.ak Existing Facility CINe&C �0N <br /> Program an EH d New Factl S �C_ �e. -.. .. 4 <br /> Facility ID _ _ _ Pro ram Retard ID ✓Oq ?3 <br /> FaciittyAddress �;- � t , N _44H� 4 cp <br /> (Please check the apprnpnalo description,Ira sP city size,aumbor of units and got tinent Information.) pEAq ti T ANT y <br /> EQ9.Q EB2W3AA4(1600) T MENr <br /> ❑Restaurant Sealing Capacity Square Footage Food Handlers Course squired; YES Ci No <br /> ❑Commissary 0 Dry storage only Il wtvl Food�reparatian ❑Vending MachinasNumber of Urit.s <br /> _ _ <br /> ❑Rail Market----Square"oota3e_ _.... __ ❑with Meat Market only ❑ Multiple DepartmentSQ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-Maae Vehicle Type Color <br /> Registration 4 L;cense k _. - <br /> 5ticker 8 <br /> 0 Mobite Food Prep Unit Make _. <br /> _ Vehicle Type Registration A Licerk5a# Stiokcr x Color <br /> Sr-Tomporary Food Facility pates of operation from 4. <br /> ('t _ ) to jvr_iO {._7 t: .�_.._ Q Ice Plant <br /> 0 Special Event Date, <br /> of operation from Q Produce Stand <br /> f'^^ to _. <br /> I}AIAY PROGRAM(20(X} <br /> ❑Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unii <br /> CVP 0 State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> Q Hazardous Waste Generator----- --Tons Gererated Per Year ❑Aecycle/Exampt System(2299) <br /> ®CRT Oftstta Handers(2216i -------—----❑Silver Only(2222) ❑Appliance Fiecyciers(2217) <br /> Tiered Permitting Facility--------- -0 Condihonaihi Authorized(CA) ❑C orditionaliy,Exempt(CE) <br /> Q Permit-By-Rule Fixed Unit Q Permit-By-Rule Household Hazardous Waste <br /> 0 ABOVEGROUND STORAGE TANK FACILITY(AST)(2390i Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ©Hotel/Motel-----Number of Units Jail or Exempt Institution--Number of Units _v <br /> Employee Housing(2700)Use 6m00yee Hoasfnwtabor Camp Apoflcatfon Form <br /> N E MMGAT�ON(2900< VNDERGPOJND INJECTION CQNTRpi_'3000) <br /> ❑ Environmental Assessment 0 UST-GAP Site ❑ Local HW Cleanup Site Q NPLISEP Cleanup Site Q UIG Site <br /> ❑ Abandoned HW Site ❑ non-NPLJSEP Cleanup Site ❑RWOCB Cleanup Site 0 Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3640) <br /> Number of PooistSpas at Facility _ ❑Pool ❑Spa ❑Out of Service Poot/Spa 0 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(400C) <br /> 0 Poultry Farm---Maximum number of birds Q Kennel <br /> TATTOO,BODY PIERCING.PERMANENT COSMETtC PRpGRAM(4140) <br /> ❑Tattooing(4121 i 13 Body Piercing(4'20) ❑ Permanent Cosmetics(4122) <br /> ►�51ViQ WASTE PROCRAM,4200) <br /> Q Pumper VehfcieFiegistiration 1F�_ ._ license#__ C aat <br /> r <br /> aP Y Vehicle# 'i <br /> ❑Pumper Yard 0 Package Treatment Plant ❑Chemical Toilets---Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ©SiudgerAah Site <br /> O Waste Tire Facility Q Compost Facility ❑PrOcess/Recycle Facility ©CiA Landfill Site <br /> O Refuse Vehicles(w or u,cs) .---.._...- ❑ Dumpsters>20 cu yd(A or Lnngi ©Farttt/itanCh Cleanup Site <br /> tuEDICAL WASTF aat�r asu(4500) <br /> 0 Primary Care ❑Acute Care 0 Skilled Nursing ❑ Large Generator Q Small Generator Q Limited Hauler <br /> ❑Transfer Station 0 Veterinary Clinic Q Common Storage Facil <br /> ag tty Lj 2 10 ❑11 -60 ❑>60 generators <br /> Pi PL#lg WATER SYSTEM PA09-RAM(4500) Use PINS EHD 46-M pry Shm, ficaf�Pb� <br /> �+ EmE NMY NOTirwiON FOR T}(S FOr`it I h U <br /> CONTACT PERSON —J l}Y t TY°M�°R pR0 RAM �,,�, )3 <br /> •--.__ Day Fh Ph � x3� e <br /> _�C �a <br /> PROGRAM ELEt4i.�.,(N'f p FEE... ,5 _ Q Surcb F Q OtherFEt <br /> l 6 PERMIT VALID <br /> IwscacTOa# �M✓ to Z ❑Food Handler <br /> z <br /> ❑a+edc a A�nuw PAID Date INVOICE <br /> Q Gash RevwwEO BY AccouNTivG OFricE Date ' <br /> 4J i Tl T�0 all�s�Itw�ttr�� A4ASTEAFiLE RECORD INFOAMATPIN3( <br />