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g" "N JO QUIN COUNTY I 1RONWNTAL HEALTH DEPAR ENT <br /> MASTERF LE RECORD INFORMATION FORM <br /> ❑New EH Pro am and New Facility <br /> ew EH Program at Existin Facili <br /> 3 L4Pro ram Record ED <br /> Facility ID - w A �� $ 1 <br /> Facility Address 0 N - T� <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD P_ ROGRAM(1600) _ -- Food Handlers Course required:—YES❑ -NO ❑--- -- <br /> ❑Restaurant: Seating Capacity Square Footage - - <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br /> ❑Vending Machines—Number of Units <br /> 11 with Meat Market only ❑ Multiple Departments ❑oPrepackaged Goods Only <br /> ❑ Retail Market----Square footage <br /> Sticker <br /> ❑ Mobile Food Vehicle----Make Vehicle Type #License` <br /> Registration# - Vehicle Type Color <br /> El Mobile Food Prep Unit--Make License" Sticker# <br /> Registration# to —0 Ice Plant <br /> ❑ Temporary Food Facility-----Dates of operation from ❑ Produce Stand <br /> Cl Special Event --Dates of operation from <br /> to <br /> DAIRY_ PROGRAM(2000) 13 Milk Dispenser---Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy 11 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> ,HAZARDOUS WASTE PROGRAM(2200) ❑ Recycle/Exempt System(2299) <br /> Tons Generated Per Year <br /> ❑ Hazardous Waste Generator------- ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> ❑ CRT Offsite Handlers(22 18) <br /> Tiered Permitting Facility — ❑ Conditionally Authorized(CA) ❑ ConditionaRu exempt hold Hazardous Waste <br /> ❑Pemtit-By-Rule Fixed Unit ❑Perrtu- <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> t) t I <br /> 'UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use <br /> HOUSING G PROGRAM(2400) ❑ Jail or Exempt Institution--Number of.Units <br /> ❑ Hotel/Motel-------Number of units <br /> Employee Housing(2700)Use Employee Hous__ /Labor ...NDERGROUND INJECTION CONTROL(3000) <br /> leanup,Site [3 UIC Site <br /> SITE MITIGATION(2900) <br /> Site <br /> leanup Site <br /> 11 Environmental Assessment ❑ non-NPLpSEP Cleanup Site Local H3❑CR`vQCB Cleanup❑Site PL/s❑ Water Quality Remediation Site <br /> El Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600)Pool 0Spa [I out of Service PooUSpa ❑ Natural Bathing Area <br /> Number of pools/Spas at Facility <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WAS TE PROGRAM(4200) License# Capacity Vehicle# <br /> �� <br /> ❑ Pumper Vehicle--Regisnation# ❑❑ Package <br /> Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> ❑ Pumper Yard <br /> WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> SOLID <br /> ❑Transfer Station ❑ Ag/Cannery Waste Site [I CIA Landfill Site <br /> ❑ Landfill El pracess/Recycle Facility <br /> ❑ Waste Tire Facility E] Compost Facility ❑Dumpsters>20 cu yd---Number of Units <br /> ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles--Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> 0 <br /> au er❑ Primary Care ❑ Acute Care ❑>60 generators <br /> [].Common Storage Facility----- <br /> ❑ 2- I O------❑ 11 -60----- <br /> ❑ Transfer Station ❑Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIPS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> Day Ph — <br /> CONTACT PERSON ❑ Surchae FEE [:] Otber FEE�� <br /> q rg <br /> PROGRAM ELEMENT 6 FEE t0 El Food Handler — <br /> INSPECTOR# R't pERMrr VALID �� INVOICE# <br /> AMOUNT PAID. Date <br /> ❑ Check# Date <br /> ACCOUNTING OFFICE <br /> [I Cash REVIEWED BY Masterfile Record Pink <br /> 4M2-034 <br />