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==MASTERFILE <br />UNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />RECORD INFORMATION FORM <br />fl n..,,., PP Prnnram at Frierinn Farililtv New EH Proaram and New Facility <br />RecordlD <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -Make <br />Registration # <br />❑ Mobile Food Prep Unit- Make <br />Registration # <br />❑ Temporary Food Facility -Dates of operation <br />❑ Special Event -Dates of operation from <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />_ to�-- [3I e Plant ❑ Produce Stand <br />to tid CFO A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Nu er of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Programacility ❑ Program 3 Facility <br />El Hazardous Waste Generator (2200)----> -Tons Generated Per Year <br />❑ Tieted Permitting Facility---> ❑ CA (2232) ❑ CE (2233,2 234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br />❑ Other CUPA Program <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 />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM <br />Number of Pools/Spas at Facility l{J Pool ❑ Spa <br />VECTOR CONTROL PROGRAM (4000) / <br />❑ Poultry Farm—Maximum number of birds <br />TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4140) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) pAYMENT <br />❑ Pumper Vehicle Registration # License # Capacity RECENPRIe # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Numb fer�fnts'o <br />SOLID'INASTE PROGRAM (4400) bEt U 0D <br />❑Landfill ❑Transfer Station ❑ Ag/Cannery Waste SitesM.'�s` h Site <br />❑ WAte Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility & FAf`G'nWfill Site <br />❑ Refuse Vehicles (#of Units) ❑ Dumpsters > 20 cu yd (# or Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11-60 ❑ > 60 generators <br />❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACTPERSON� -1 ),C� DayPhiLIO)>) Night Ph�-0�lkl�S-- <br />PROGRAM ELE ENT D FEE ❑ Surcharge FEE '7 ❑ Other FEE <br />INSPECTOR# PERMIT VALID t,2 -Q - 2-d t Z 11 Food Handier <br />Check # AMOUNT PAID Date 2,C21 INVOICE # <br />C' Cash REVIEWED BY ACCOUNTING OFFICE Date <br />