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f !!! COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Program al Exlstin FacilityNew EH Program and New Faclll FacilityID Program Record ID Facility Address I (Please check the appropriate description and specify size,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 ❑Vending Machines Number of Units ❑ Retail Market--Square footage ❑w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle—Make Vehicle Type Color Registration I License# Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility—Dales of operation from to ❑ Ice Plant 11 Produce Stand 11 Special Event—Dales of operation from to CFO M A❑ B DAIRY PROGRAM(2000) ❑ Grade A Dalry ❑ Grade B Dalry ❑ Milk Dispenser-Number of Containers in Multi-Head Unit COPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)--->-Tons Generated Per Year ❑ Tiered Permitting Facility--> ❑CA(2232) ❑CE(2233,2234,2235,2237) ❑ PBR(2231) ❑PBR HHW(2236) ❑Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑Underground Storage Tank Program(UST)(2300)Use UST A and B forms ❑Other CUPA Program HOUSING PROGRAM(2400) ❑ HotellMotei--Number of Units ❑J211 or Exempt Institution—Number of Units Employee Housing(2700)Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑RWOCB Cleanup Site ❑Water Quality Remedlatlon 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) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) ❑Body Art Facility-Sterilization(4121) ❑Body ArtTemp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistration# License# Capacity Vehicle# E3 Pumper Yard ❑ Package Treatment Plant ❑Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑CIA Landfill Site ❑Refuse Vehicles(#or Units) ❑ Dumpsters>20 cu yd IN or Units) _ ❑ FarmlRanch 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 PWS EHD 4602.003 Blue Application Form TIFICATION FOR THIS FACILITY AND/OR PROGRAM �f�� p �+ CONTACT PERSONR ENCY Day Ph Night PlIza 11!✓—p�2_I PROGRAM ELEMENT FEE ❑Surcharge FEE ❑Other FEE INSPECTOR# PERMIT VALID l0 ❑ Food Handler ❑ Check# AMOUNTPAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02434 MASTERFILE RECORD INFORMATION PINK 723/13