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IN COUNTI ONMENTAL HEALTH DEP 1- VT <br /> _ MASTERFILE RECORD INFORMATION FORM <br /> 4New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID F,q po&[6S Program Record ID <br /> Facility Address . 9 10 C ve f Ie ("6,V1 61 . <br /> (Please Check the appropriate description and specify size,number of units and Dertinent 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 ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-----Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-- ,,umber of Containers in Multi-llead Unit <br /> CUPA ❑ State Facility-Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility------------------❑ 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 LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotel/Motel-------Number of Units ❑ Jail or Exempt Institution------Number of Units <br /> Employee IIousing(2700) Use Ernplovee llousine/Lahor Cmmn Application Form <br /> SITE MITIGATION.(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW'Cleanup Site ❑ NPL/SEP Cleanup Site Cl UIC Site <br /> ❑ Abandoned IIW 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 Sen•ice Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM,(4000) <br /> ❑ Poultry Farm -------Maximum number of birds ❑ Kennel <br /> TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM(4 100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle -Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> 15UWaste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Nwnber of Units ❑ Dumpsters>20 cu yd----Number of Units _ ❑ Fann/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care El Skilled Nursing 11 Large Generator ❑Small Generator 13 Limited Hauler <br /> ❑ "Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----❑ 2- 10------- ❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM,(4600)Use PIVS EHD 46-02-003 Blue Anplication Form <br /> EMERGENCY NOTIFICATION FOR THtS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PItOGRANI ELEMENT I'I1q o FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 00(/;() PFRM(T VALID to ❑ Food Handler <br /> ❑ Check q AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY J 11 OS' ACCOUNTING OFFICE Date <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />