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E AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ogram at Existin Facility ❑New EH Program and Nen'Facility Oft S Program Record II) 5 C3 Facility Address Z-4' 2 S . 4�a-r 6414 (Please Check the appropriate description and specify s,ize,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines—Number of Units ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only to Mobile Food Velricle---Make_� Vehicle Type Color Registration# License# _ Sticker# Vkhlobile Food Prep Unit—Make 6�1C, Vehicle Type Color Registration# I tjr-7 P92,A!g¢l_3Sn t 9�S6 License# Sticker# " ❑ Temporary Food Facility—Dates of operation from to MIce Plant ❑ Special Event —Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(20W) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser--Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms ROUSING PROGRAM(2400) ❑Ilotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employ"housing(2700)Use Employee Ilousine/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UTC Site ❑ Abandoned IfW Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Stare ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Rauch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2- 10 ❑ 11-60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff'S F,IID 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR'rltms FACILITY ANO/OR PROGRAM CONTACT PERSON 4�- 1 C Day Ph'c' C Z- light Ph I'ROGRAM ELENIENlr FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# O PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date (� INVOICE# 0 Cash REVIEWED BY ACCOUNTING OFFICE Date 91