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fMASTERFILE <br /> COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH Progm and New Facility <br /> Facility ID 1 r Pro ram Record H) J✓ " � <br /> Facility Address `t 7 �5y`) � P E) k7Y- A-V 5 t' <br /> (Please Check the appropriate description and specify s, M number of units tmd pertinent informat' n.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required:.. Yes L1No 11 <br /> ❑ Commissary ❑ Drystorage only ❑with Food Preparation ❑Vending 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 ❑hulk Dispenser—Numbs of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS IVASTE PROGRAM(2200)- - i <br /> ❑}lazardous Waste Generator. Tons Generated Per Year -❑ Recycle/ eSystem(2299) <br /> H CRT Offsite Handlers(2218) ❑ Silver Only(2222) c ❑ Appliance Recyclers((2217) <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 UST A and B forms - <br /> HOUSING PROGRAM(2400) <br /> ❑HoteVMotd—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use FmPloreeTfousinzIlbor Camp APPfit¢riorc Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Load 11W Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediatiou Site - <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of Service Pool(Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm—Maximum number of birds ❑ Keuael <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 /> ❑ 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 cu 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 IIauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2-10—❑ 11-60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EFID l6-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THrs FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE '- 11 Other FEE <br /> INSPECTOR# PERMrf VALID . to 1:1 Food handler <br /> ❑ Check# AMOUNT PAID Date INVOICE#/� <br /> 0 Cash REVIE Er)BY 'V ACCOUNTING OFFICE Date J 3 <br />