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'E UIN COUNTY EN . :ONMENTAL HEALTH DEPARTI AT MASTERFILE RECORD INFORMATION FORM PAYMENT RECEIVED am at Existin Facility ❑New EH Program and New FacilityOO Pro ram Record ID R S3(��9 FEB 2 4 2012 �,�7� doamuwcoury Facility Address -3*5 d fi✓/ '1 t/11 "A.LTH De-A "` (Plcase heck the appropriate description and specify siz cumber of units and mertinent' formation.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes❑ NO�k ❑ Commissary ❑ Drystorage only ❑with Food Preparation ❑Vending Machines Number of Units ❑Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# LITentporary Food Facility--Dates of operation from - to ❑ Ice Plant . ❑Special Event —Dates'of operation from - to ❑Produce Stand DAIRY PROGRAM(2000) ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit CUPA ❑State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200)" - S ❑Hazardous Waste Generator.- Tons Generated Per Year ❑Recycle/Ezempt System(2299) ❑ CRT Offsite Handlers(221 s) ❑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 HOUSING PROGRAM(2400) _ ❑Hotel/Motel—Number of Units 11 Jail or Exempt Institution Number of Units Employee Housing(2700)Use Employee Rousing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 0 Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. 1 ❑NPLISEP Cleanup Site ❑UIC Site ❑Abandoned HAY Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) - Number of Pools/Spas at Facility. ❑Pgol ❑ 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) ❑Tattooiag(4121) ❑Body Piercing(4120) - ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License Capacity Vdiicle# ❑Pumper Yard ❑Package Treatment Plant ❑ ChemicalToilets—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/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled"Nursing ❑Large Generator 13 Small Generator ❑Limited Hauler ❑Tmusfer Station ❑Veterinary Clinic ❑Common Storage Facility--0 2-10—❑ 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use Plf'S F11D 46-02-003 Blue Application Fonn � ^EM_E,RGENCY NOTIFICATION rOR THIS FACILITY ANOIOR PROGRAM CONTACT PERSON t^,' / Day Ph Night Ph PROGRAM ELEMENT I � �} 7. — FEE [] SurcliargeFEE 2 ❑ OtherFEE 77 INSPECrOR# f r)g�PETRMIT VALID 7i to 7/ Z D 1 ) ❑ Food Handler ❑ Check# AMOUNT PAID I i 0� 1ry� Dale ti INVOICE# 22�� Cash REVIEWEDDY ACCOUNTING OFFICE Date —2 .., -1. Record Pink