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IffQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New Ell Program and New Facility <br /> Facility ID ' _ Pro ram Record ID N�Y`� i�� <br /> Facility Address X 3 2 r 5'- U S <br /> (Please fleck the appropriate description and specify ijM number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food handlers Course required: Yrs❑ No❑ <br /> ❑ Commissary ❑ Drystorage only ❑ with Food Preparation ❑Vendiag Machines—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 —Dates of operation from - to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) - <br /> ❑Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) 4 <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle f Exempt System(2299) <br /> ❑ CRT Offsite Handlers(221 s) ❑ Silver Only(2222) _ ❑ Appliance RLeyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pemut-By-Rule Fixed Unit ❑Permit y-Rule Household Hazardous Waste <br /> ✓,ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms,/ <br /> , <br /> HOUSING PROGRAM(2400) <br /> [IHoteVMotd Number of Units ❑Jail or Exempt Inti 'on—Number of Units <br /> Employee Ifousing(2700)Use Employee Housin&Labor Camp ApRucation Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P991 ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 11 Poultry Farm—Maximum number of birds _ 13 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ElPumper Yard ❑ Package Treatment Plant ❑Chemical Toilets—Number of Units - <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag 1 Cannery Waste Site ❑ Sludge(Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Duntpsters>20 cu yd—Number of Units ❑ FarmlRanch 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-0 2-10—❑ 11-60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS E11D 46-01-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR TH75 FACILITY ANOIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAMELENIEN'r FEE ❑ Surcharge FEE . ❑ Other FEE <br /> INSPECTOR#e D PEEMFrVALID . to ❑ Food Handier <br /> ❑ Check# AMOUNT PAID Date INVOICE# _ <br /> 0Cash REVIEWEDBY ACCOUNTING OFFICE i Date -% / <br />