Laserfiche WebLink
ESANJOA QU IN COUNTY EN NMENTAL HEALTH DEPART* <br /> MASTERFILE RECORD INFORMATION FORYI <br /> C&New EH Program at Existing Facility ❑New EH Program and New Facility I'v <br /> =F�acilitD G d°1 L-'`,L Program Record ID <br /> Facility Address �:n�o IylI&r,G6 �� <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage <br /> Food Handlers Course required: Yes ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units <br /> El Retail Market- -Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> [I Mobile Food Vehicle-----Make yp Sticker# <br /> Registration# License# <br /> Vehicle Type Color <br /> El Mobile Food Prep Unit-Make yp Sticker# <br /> Registration# License# <br /> 11to Ice Plant <br /> 11 Temporary Food Facility-----Dates of operation from ❑ Produce Stand <br /> ❑ Special Event --Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> ❑ Milk Dispenser--Number of Containers in Multi-Head Unit <br /> El Grade A Dairy ❑ Grade B Dairy <br /> CUPA ❑ State Facility-Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) Recycle❑ /Exempt System (2299) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year Y <br /> ❑ CRT Offsite Handlers (2218) El Silver Only(2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facility'------------------El 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 GSTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution-------Number of Units <br /> E] Hotel/Motel-------Number of Units <br /> Employee housing(2700) Use Employee FlousinolLahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB 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) ❑ Kennel <br /> ❑ Poultry Farm -------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4 100) <br /> El Tattooing(412 1) <br /> 11 Body Piercing(4120) ❑ Permanent Cosmetics(4 122) <br /> LIQUID WASTE PROGRAM(4200) License Capacity <br /> Vehicle# <br /> C1 Pumper Vehicle -Registration# <br /> # <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash a/Ash Site <br /> El Landfill El Transfer Station ❑ Ag/Cannery Waste Site g <br /> ElProcess/Ree Process/Recycle Facility El CIA Landfill Site <br /> D� Wa�tc"fire Facility E] Compost Facility El ❑ F,t+tit/Ranch Cleanup Site <br /> ❑ Itef u,e Vehicles--Number of Units _____ ElDumpsters>20 cu yd----Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care ❑ Skilled Nursing El Large Generator ❑Small Generator ❑ Limited Mauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10------- ❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PR'S EHD 46-02-003 Blue Aeplicatio n Foran <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> I FEE ❑ Surcharge FEE ❑ Other FEE <br /> rP110GRAM ELh�IENI' / , ❑ Food Handler-__._►�:croti#y�;+ iPL'RMLT VALID to <br /> AMOUN fPAIDDate I2ate <br /> G <br /> heck tt L —7 E�Cash RE\'IE�1'ED dl' <br /> ACCOUNTING OFFICE <br /> Master cord Pink <br /> 48-02-034 <br /> 10/6/2003 <br />