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E!!! <br />AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at <br />Facility ID LA,^D <br />Facility Address <br />{Please check the appropriate description and specify ss✓ number of unit <br />FOOD PROGRAM (1600) <br />❑ Restaurant Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market—Square footage ❑ w/Meat Market only <br />❑ Mobile Food Vehicle –Make Vehicle Type <br />Registration # License #_ <br />❑ Mobile Food Prep Unit– Make Vehide Type . <br />Registration # License #_ <br />❑ Temporary Food Facility–Dates of operation from <br />❑ Special Event ---Dates of operation from to <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending MachinesNumberof Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />_ color <br />Sticker # <br />Color <br />Sticker# <br />to �L_ 11Ic9,,PIant ❑ Produce Stand <br />I!VCFO ❑ B <br />DAIRYPROGRAM (2000) <br />Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit _ <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program *Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200)- >-Tans Generated Per Year <br />❑ Tiered Permitting Facility---> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program US (2300) Use USIA and B forms <br />❑ Other CUPA Program , <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel—Number of Units ❑..Vail or Exempt Institution ----Numlber of Units <br />Employee Housing (2700) Use Employee Housina/Labor Camp Application Form <br />SITE (MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH IPROGRAM (3600) <br />Number of Pools/S,pas at Facility _ ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ------Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa <br />TATTOO, IBO,DY IPIIEIRCING, PERMANENT COSMETIC PROGRAM J41 00) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (41 15) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) <br />LIQUl!D WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration# <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles (#of Units) <br />❑ Natural Bathing Area <br />❑ NYMENT <br />EI Body Art Facility -Single WWED <br />❑ Body Art -Temp EveiApkbjltF kIlity (4131) <br />Capacity SANI9t pU <br />ElChemical Toilets----Numberp mB� ETM <br />❑ Ag/Cannery Waste Site <br />❑ ProcesslRecycle Facility <br />❑ Dumpsters> 20 cu yd (#of Units) <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ Farm/Ranch Cleanup Site <br />IMEDICAL 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 />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACTPERSON <br />PROGRAM ELEMENT Ik <br />INSPECTOR# <br />❑ Check # vII] r1 <br />- 1 fthA <br />Day Ph <br />I FEEIL-UU [IS u�rc,/h ge FE 1:1 Other FEE <br />PER�MITVALID 'y Z to "I1 ❑ Food Handler _ <br />AMOUNT PAID ISC' ,– Date /� INVOICE# <br />