Laserfiche WebLink
_ Lf!! <br /> IN COUNTY ' - IVIRONMENTAL HEALTH DEPAF SENT <br /> MASTERFILL-RECORD INFORMATION FORM � O <br /> ❑ New EH Program at Existing Facility New EH Program and New Facility ) PI <br /> Facility ID ft 41111D;? FftA , Program Record ID - 1 3 ✓ �— <br /> Facility Addresses !� <br /> (Please check the appropriate description and specify size number of units and.pertinent information .) 0Cl ' <br /> FOOD PROGRAM (1600) <br /> ID Commissary 11 Dry storage only <br /> 11Restaurant: Seating Capacity _ Square Footage Food Handlers Course required: YES 13No ❑ <br /> El Retail Market---Square footage 13 with Food Preparation ❑Vending Machines Number of Units <br /> ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle —Make Vehicle Type <br /> Registration # Color <br /> ❑ Mobile Food Prep Unit License # Sticker # <br /> Make Vehicle Type <br /> Registration # License # Color <br /> Sticker # <br /> 11 Temporary Food Facility --Dates of operation from to <br /> ❑ Special Event Dates of operation fromto ❑ Ice Plant DAIRY PROGRAM (2000) 13 Produce Stand <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge (2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ Hazardous Waste Generator ----------- Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br /> ❑ CRT Offsite Handlers (2218) ------------ ❑ Silver Only (2222) ❑ 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 USTA and B forms <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel ----Number of Units ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> El Environmental Assessment ElUST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation 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 <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Kennel <br /> ❑ Tattooing (4121 ) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br /> LIQUID WASTE PROGRAM (4200) <br /> ❑ Pumper Vehicle Registration # License # <br /> 1:1 Pum er Yard Capacity Vehicle # <br /> P ❑ Package Treatment Plant <br /> SOLID WASTE PROGRAM (4400) 11 Chemical Toilets ----Number of Units <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br /> ;Haste Tire Facility ElCom Compost Facility El Sludge/Ash Site <br /> P Y ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles O of Units) ❑ Dumpsters > 20 cud mor units <br /> MEDICAL WASTE PROGRAM (4500) y I ❑ Farm/Ranch Cleanup Site <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator <br /> ❑ Transfer Station ❑ VeterinaryClinic 1:1 Small Generator Limited Hauler <br /> ❑ Common Storage Facility ❑ 2 - 10 011 - 60 ❑ > 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph <br /> Night Ph <br /> PROGRAM ELEMENT iG :30 FEE ❑ Surcharge FEE El Other FEE <br /> INSPECTOR # r7CF� PERMITVALID t0 <br /> ❑ Check # AMOUNT PAID El Food Handler <br /> Date INVOICE # <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE � y <br /> /jA� Date Vvic <br /> 48-02-034 <br /> 11 /15/07 MASTERFILE RECORD INFORMATION PINK <br />