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:S1DAQUI COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FPKM ❑ New EH Pro ram at, :isting Facility ew EH Pro ram and New Facility Facilit ID_ Program Record ID L 7 Facility Address 14 �� S L (Please check the apprc iate description and specify slie, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YI s❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market---Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicl --Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Regi 'ration# License# Sticker# ❑ Temporary Food Fa . Iity--Dates of operation from to ❑ Ice Plant ❑ Special Event Dater of operat�ion�m to ❑ Produce Stand DAIRY PROGRAM (2000) 1J ((s Sq ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facili ,Surcharge(2399) HAZARDOUS WAS PROGRAM (2200) ❑ Hazardous 1r'Jaste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) ❑ CRT Offsite I landlers(2218) -------------El Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitti-3 Facility -------------------11 Conditionally Authorized (CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Ilazardous Waste ❑ ABOVEGRC IND STORAGE TANK FACILITY(AST) (2390) Number of AST UNDERGRC 'ND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B forms HOUSING,PROGRAM(24 )) ❑ Hote°/Motel------Nun er of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing(270C; Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Fools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poul ry Farm-------Maximum number of bir 1s ❑ Kennel TATTOO,,BCDY PIERCIN PERMANENT COSMETIC PROGRAM (4100) ❑ Tattcoing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics(4122) LIQUID WAS-I E PROGRA :_(4200) ❑ Pumper Vehicle Rec stration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units__ SOLID VVASTFc PROGRAP (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Was'y Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ RefU:.e Vehicles (#or Units) ❑ Dumpsters>20 cu yd (#of Units) ❑ Farm/Ranch Cleanup Site MEDICA' WASTE PROGRAM(4500) ❑ Prirtt:pry Care CI Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Tran:;fer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC'VATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTA :T PERSON I Day Ph , 16K✓ Night Ph PROGRr M EL ENTIALI FEE I ❑ Surcha ge FEE ❑ Other FEE INSPECT(,R# PERMIT VALID to d Z ❑ Food Handler ElCher':# _ AMOUNT PAID (' Date NVOICE# 3 Cash R[VIE'-CD BY i j2LA ,4 ACCOUNTING OFFICE Date 48-02-03-' MASTERFILE RECORD INFORMATION PINK 11/15/07