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Case Study on Environmental Health Food Safety Division Program

Running head: ENVIRONMENTAL HEALTH DIVISION FOOD SAFETY PROGRAM Environmental Management Department of Sacramento County: Environmental Health Division Food Safety and Protection Program Table of Contents Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 4 History and Development . . . . . . . . . . . . . . . . . . . 5 Goals and Objectives . . . . . . . . . . . . . . . . . . . . . 6 Description of Services . . . . . . . . . . . . . . . . . . . 9 Levels of Intervention . . . . . . . . . . . . . . . . . . . 9 Goal and Objective Relevance . . . . . . . . . . . . . . . . . 10 Target Population . . . . . . . . . . . . . . . . . . . . . .11 Program Evaluation . . . . . . . . . . . . . . . . . . . . . .12 Program Funding . . . . . . . . . . . . . . . . . . . . . . . 13 Personnel Qualifications . . . . . . . . . . . . . . . . . . . 16 Current Status . . . . . . . . . . . . . . . . . . . . . . . .19 Future Needs . . . . . . . . . . . . . . . . . . . . . . . . . 21 Changes to the Program . . . . . . . . . . . . . . . . . . .23 References . . . . . . . . . . . . . . . . . . . . . . . . . .26 Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . .28 Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . .29 Appendix C . . . . . . . . . . . . . . . . . . . . . . . . . .30 Appendix D . . . . . . . . . . . . . . . . . . . . . . . . . .32 Abstract Food is a vital ingredient to the survival of life on earth. Food gives people the energy to carry out everyday tasks. With food being so important to life, should it not be of highest quality?

Food is prepared, cooked and consumed every minute of every day. How do consumers know that the food is safe? The group members of We 8 A Lot went on a mission to find out exactly how food consumers are protected and by whom. Through research and interviews with the Environmental Management Department of Sacramento County, it was found that there are a group of individuals who work diligently to protect food consumers by inspecting the 6,000 food facilities in Sacramento County. ENVIRONMENTAL MANAGEMENT DEPARTMENT OF SACRAMENTO COUNTY:

ENVIRONMENTAL HEALTH DIVISION FOOD SAFETY AND PROTECTION PROGRAM Introduction For the case study, our group chose to investigate the Food Protection Program that resides within the Environmental Health Division which operates under the umbrella of the Environmental Management Department (EMD) of Sacramento County. The functions of this department not only protect residents and consumers of this county in the matter of retail food safety but, also by the regulation and enforcement of water protection and hazardous materials.

On October 1, 2004, an interview was conducted at the Environmental Health Division office located at 8475 Jackson Road, in Sacramento, with June Livingston, Communications and Media Officer and Richard Sanchez, Environmental Program Manager. In the interview, Mr. Sanchez revealed that there are “close to 6000, food facilities in this [Sacramento] county” (personal communication, October 1, 2004) With this many retail food facilities in Sacramento County and the consumer culture of Americans, the potential for food-borne illness is staggering.

Just one instance of improper handling, storage, or cooking of foods in retail food facilities can cause serious outbreaks of infections or in severe cases, death. On average, each day in the United States alone, “over 200,000 people fall ill with a food-borne illness and of those, fourteen will die” (Sizer & Whitney, 2003, p. 511) Keeping this in mind and the fact that food is one humanity’s most basic needs for survival, this agency most definitely warrants study. Since our team was quite large, 8 members, and relative to food, we decided to name it, “We 8 a lot”. Similarly, due to our team size we decided to split it into halves.

One-half of the team devoted their efforts to online and print research while the other half focused on interview and personal communication research. Project tasks were divided between the team members and each member was deemed responsible for his or her content area. Moreover, leadership positions of paper editor, Power Point manager, and team recorder were established on a volunteer basis to avoid any confusion during the project. The members of this team, listed alphabetically are: Simranjot Bains, David Chan, Lynn Gervacio, Safiya Nuur, Joy Pastones, Shantell Payne, Valerie Quitoriano, and Yvonne Rains.

History and Development Prior to becoming a department, EMD program elements were housed in the County Health Department. But in 1988, the Sacramento County Environmental Management Department (EMD) became a consolidated, freestanding department consistent with separate City and County advisory body recommendations to merge and augment environmental regulatory activities. Initial program elements included Air Quality, Environmental Health (includes Food Protection Program), and Hazardous Materials Divisions. The Sacramento Air Quality Management District separated from EMD and County Government in 1995.

The Environmental Management Department currently has three operating divisions, with Water Protection which was added in 2003. The organizational chart in Appendix A shows the various divisions of the Sacramento County. The Environmental Management Department is one of ten county service agencies. The organizational chart in Appendix B shows how the EMD is further divided. Within the Sacramento EMD, there are three subdivisions that have been listed above. Under the Water Protection, Environmental Health and Hazardous Materials Divisions, there are also a number of subdivisions.

Goals and Objectives The Food Protection Program, which is part of the Environmental Health Division (EHD), is responsible for regulation and enforcement of state and local health codes at all retail food facilities in Sacramento County and all incorporated cities. The mission of the agency is to protect the health of the public from unsafe food, water and hazardous materials. The Food Protection Program’s goal is to ensure food safety practices at all retail food facilities in Sacramento County and to become a world leader in terms of clean and uncontaminated food (http://www. hs. ca. gov/ps/fdb/HTML/Food/indexfoo. htm). Achieved Goals The Food Protection Program of Sacramento County has achieved many goals. First, the agency has increased the number of inspections from once a year to twice a year for facilities that prepare food. Second, it has developed an enhanced “Prioritized Inspection Frequency Compliance” on their website to assist businesses in the county (http://www. emd. saccounty. net/Documents/Info/Bulletin0503-prioritized_inspection_frequency. pdf. ). This site answers many questions and has information about the laws and requirements.

Third, as of July, 1 2003, the Food Protection Program has mandated all businesses to post their most recent inspection report in a visible place for customers to read. Fourth, the agency has “initiated an ‘Award of Excellence’ in Food Safety to recognize operators of food facilities in Sacramento County and all incorporated cities who exhibit excellent food safety and sanitation standards” (http://www. emd. saccounty. net/EH/EMDFoodSafetyAwards. htm. ). Long Term Goals The Food Protection Program also has many long-term goals.

First, the program seeks to increase the surveillance on food markets such as Raley’s, Bel-Air, Albertsons, Safeway, and smaller, family owned markets. The program wants to inspect these businesses twice a year instead of the current one-year inspection. The second long-term goal of the program is to change from hand written inspection reports to computer-based inspections. In order to do this, the program needs to purchase additional equipment such as laptops or some other computer devices that would allow employees to type their inspection.

In order to achieve these goals, the program needs to save money and implement additional training for their employees. (personal communication, September 18, 2004). The third, long-term goal of the Food Protection Program is to generate more interest in this field. Ms. Livingston, who is the Communications and Media Officer of the Environmental Management Department, commented that “the people [public] are not quite sure who does th[is] work”, referring to the functions of EMD. Ms. Livingston also commented that they will do more “outreach and awareness programs to let people know that food protection is profession (personal communication, September 18, 2004). Description of Services Some of the services the Food Protection Program provides are permitting, inspecting and re-inspecting of retail food facilities. The agency also provides food safety education to train employees of food facilities to improve compliance in terms of food safety regulations and reduction of the incidence of food borne-illness. It also issues permits for new businesses and provides outreach programs for the public. The Food Protection Program investigates complaints and suspected cases of food borne-illnesses when they do occur.

Finally, as a last resort, the agency can enforce closure of food facilities with consistent non-compliance (http://www. emd. saccounty. net/pdf/CURFFL. pdf. ). Levels of Intervention The levels of intervention of the Food Protection Program function on primary, secondary, and tertiary levels. Primary prevention of the agency is enacted through education, outreach, regulation, and inspection. The agency inspects food facilities to prevent contamination of food and food borne-illnesses from the public. Secondary prevention of the Food Protection Program is accomplished through the re-inspection process.

When businesses have major violations, they are given a two week period to correct the problem. Once the problems have been corrected, the re-inspection process ensures compliance. Finally, the tertiary level of prevention of the Food Protection Program closes food facilities that have consistent major violations and or violations that are not corrected in a timely fashion. Major violations are those that pose public health hazards such as contaminated equipment (personal communication, September 18, 2004). Goal and Objective Relevance The goals and objectives of the agency address the human ecology and heath studied.

The agency provides educational programs through scientific principals to protect the heath of the public and the environment. The Food Protection Program Agency completes these tasks through teamwork and a cooperative approach (http://www. emd. saccounty. net/pdf/CURFFL. pdf). As Richard Sanchez, emphasized, “the point [of the program] is not to try and fine people, but the first thing we want to do is to educate people and help them understand what it is that they are supposed to do (2004). ” Mr. Sanchez also mentioned that “when people know what food borne-illness is, they are less likely to violate the laws.

One of the big ones is hand washing. Something so simple can prevent so much” (personal communication, September 18, 2004). Target Population The Environmental Health Division goals are to deliver outstanding service to all Sacramento County residents including the incorporated cities of Isleton, Folsom, Elk Grove, Galt, Rancho Cordova and Citrus Heights. They also aim to service the visitors in the area as well. The population of this county is over 1. 2 million residents, which is about 1200 persons per square mile. There are food venues developing everywhere to meet the demand of the consumers.

The venues where food is served, either cooked or prepackaged, will be subject to an inspection and will be given a permit once it has passed. The typical venues consist of: restaurants (fast food, ice cream shops, delicatessens, coffee shops, sandwich shops), mobile food units, bars, taverns, commissaries, bed and breakfasts, school cafeterias, day/child care facilities, senior non-profit nutrition programs, convenience stores, dairies, and farmers markets as well as special or temporary events such as the fair, and craft or street fairs.

During the inspection, even the smallest attributes of food preparation and serving styles are observed. EHD is now striving to complete two inspections per year to better the service of the community and lessen the risk for any food-borne illnesses in the future. Program Evaluation The Environmental Health Division of the Food Safety Protection Program does not have a formal evaluation process; however, they do participate in voluntary evaluations. The purpose of an evaluation is to determine whether the objectives of the program are being met and to provide feedback to improve the program.

If we were to evaluate this program, we would use summative evaluations, which are used to determine how well the program has met their predetermined short term and long-term goals and objectives. Summative evaluations use two types of procedures, impact and outcome. Impact procedures are used mainly for immediate, short-term effects while outcome procedures are used for long-term effects. For the EHD Food Safety Protection Program, we would assess a set number of food-borne illnesses and a set number of food safety violations and then evaluate how well the program worked to make sure they did not exceed those limits.

Even though the food protection program does not have a formal evaluation process, ironically, they won a 2004 Challenge Award from the California State Association of Counties. Out of 163 Challenge Award entries from 38 counties, the Sacramento County Food Safety Education for Restaurants Program was one of the 10 recipients of the Award. The award was based on demonstrated leadership, innovation, creativity, resourcefulness and effectiveness, as well as the potential for successful elements of the program to be used as a model for other counties.

One of the reasons hypothesized why they might have gotten the award was because of their affiliations. The Food Safety Program is a member of the California Restaurant Association (CRA), where the annual membership fee is based on the gross revenue of the program. CRA has been representing approximately 20,000 foodservice establishments in California since 1906. Some of the benefits of membership in the CRA are discounts and savings on essential products, programs and services. Moreover, members are also kept informed on the latest industry issues through newsletters, publications, and resources.

Program Funding The Environmental Health Division’s financing sources come from four different areas: reimbursements, charges for services, reserve release, and other revenues. The department receives no tax money from the government; however, the department does receive some government grants, but not of any significant amount under the food program. Most of the Environmental Management Department’s large grants are given to the Hazardous materials division, rather than the Environmental Health division, under which the food program is directed.

The U. S. Federal Drug Administration did give the food program a small grant in the amount of $5,000 to get their staff training sessions. These grants are listed under the reimbursement area. The charges for services category consists of re-inspection fees, which are billed when food facilities use more time than what the permit pays for. These fees are allocated at the hourly rate of up to $149. 00. The third area, the reserve release, makes improvements possible and makes additional money available if needed.

This financial source comes from saving extra money left over from the previous month’s finances. Once there is a need for money that isn’t being met by the three other financial resources, then money is taken out of the reserve. Also if improvements need to be made, such as a new computer system, then the reserve covers this cost. The Environmental Health Division earns the majority of their revenues from the services they provide, which is listed under the other revenue area. Every food facility requires a permit from the Environmental Health Division and is charged a fee for their inspection.

Some facilities are inspected once a year, but recently the requirements changed for higher-risk facilities (food preparation sites) to be inspected twice a year. The total budget for the food program is $2,840,243, while the entire budget for the whole program is close to $13 million. Another service the Environmental Health Division provides and earns revenues from is the Food Safety Education program (FSE). The program encompasses two classes about food safety, in which they charge $20 per person for attending. They also offer to perform the classes at the actual food facility site for $400.

Despite the fact that the Environmental Health Division receives no tax money from the government, Richard Sanchez believes it is a good thing. He states that when there is a tax cut in government funding, then agencies start having to cut people. He proudly claims that they have never had to cut people, but rather they are adding positions (personal communication, September 18, 2004). In fact, most of their expenditures are from staffing fees. The other two financial uses the department covers are reserve provisions and services and supplies.

As mentioned earlier, the reserve provisions consist of extra money that is saved until further needed for improvements or in case financial sources are running low. The money spent on services and supplies is directed towards rent and office provisions. Some of the services the Food Program uses are classified into special interfund/intrafund charges and reimbursements. This would include lab analysis services from a Sacramento County agency. If the inspectors want to have a closer look at a particular facility’s food quality, then an analysis of that food would be performed.

The services used by the Food Program would not be paid in cash, rather it would be seen as a trade out to the other Sacramento agency in return for services from the Food Program such as a permit or inspection of that agency’s food facility. Personnel Qualifications Currently, in the County of Sacramento Environmental Management Department there are 110 employees. Of those 110 individuals, 27 are employed within the Food Protection Program. Employment opportunity of the Environmental Health Division varies from what is referred to as a Level I to a Level IV position of Environmental Health Specialist.

The minimum qualifications of the Level I position require one year of experience performing technical support or a completion of twelve semester units from a college or university in physical science, life science, or engineering. The salary offered to the Environmental Health Specialist I is $2509. 00 to $3398. 00 per month. The variation in salary is due to experience. If the employee has just started, the salary begins at $2509. 00, but as the person gains experience within the field, the salary increases up to a certain point; which is $3398. 0 per month. In order to grow within the field at all levels, the employee needs to complete the supplemental questionnaire, which encompasses: the employee’s level of education, experience in technical support and public health contact work, possession of current California driver’s license, knowledge of different cultures, and English fluency. Once the questionnaire is submitted, the panel group sets a date for the employee to take a test. The test is divided into ranks, and usually the first three ranks are chosen for the job.

Once, the employee has qualified, then the new title given. The position of Environmental Health Specialist II, ranges in salary from $3659. 00 to $4447. 00 per month. This employee should be able to research, interpret, and apply environmental laws and regulations. This position requires the candidate to have: (1) graduation degree in health science, public health, natural science or physical science, (2) one year of experience in environmental research or regulation, or (3) Registered Environmental Health Specialist certification.

The third level of employment known as the Environmental Health Specialist III covers field inspections and research. Some of the duties performed are: organization and analysis of environmental data collected, development and preparation of studies related to regulatory compliance, meeting with business owners to develop solutions to achieve compliance, training and guiding other staff members, and preparation of written analyses and recommendations. This position’s salary starts at $4367. 00 and ends at $5308. 00 per month.

In order to qualify for this position, the candidate must have a Master’s degree in health science, public health, physical science, or environmental health and a one-year experience in environmental inspection, enforcement, regulation, analysis, or a previous title of Registered Environmental Health Specialist II certification. Environmental Health Specialist IV is the last level of employment and in this position, the candidate is considered a supervisor and is responsible for a team of scientific, professional, and technical staff. At this level, the candidate is paid from $5392. 00 to $5945. 00 per month.

He or she plans, organizes, and reviews the work of the team. The candidate also participates in developing and implanting new policies, procedures, programs, regulations, and guidelines related to inspections, enforcement, compliance, and scientific studies. Besides these positions there are also student intern positions which require the student to perform basic duties such as answering the phone, filing, distributing the mail, and helping in research. The students are allowed to work a maximum of 24 hours per week and the only students who qualify for this position are those who are in their last year of completing their degree.

Current Status Currently, the services provided by the food safety program are mandated by the State of California in accordance with local provisions and the California Uniform Retail Food Facilities Law (CURFFL), which finds and declares that the public health interest requires that there be uniform statewide health and sanitation standards for retail food facilities to assure the people of this state that food will be pure, safe, and unadulterated. It is the intention of this Legislature to occupy the whole field of health and sanitation standards for these food facilities . . and regulations adopted pursuant to its provisions shall be exclusive of all local health and sanitation standards relating to these facilities. (http://www. Emd. saccounty. net/pdf/CURFFL2004. pdf, p. 4) Since this program is mandated by the state, the food safety program of the Environmental Health Division is at no risk for disruption or dismantling. Twenty-seven, Registered Environmental Health Specialists will continue to inspect retail food facilities twice annually (effective July 1, 2003). Although the state mandates inspection twice yearly, Mr.

Sanchez, conceded in the interview that markets such as Raley’s are only getting inspected once annually. As of the end of September, 2004, the Environmental Health Division has completed “6,132” inspections of retail food facilities and “742” inspections of area dairies (http://www. saccounty. net/pdf/EMD-2004-10_Update. pdf. , p. 4). Aside from routine inspections and re-inspections of retail food facilities, Environmental Health continues to offer food safety education and certification classes as well as community outreach events designed to inform consumers and retailers about food safety and compliance with state and local health codes.

This group attended an outreach event held at Carmichael Park, on September 18, 2004, where the Environmental Health Division booth activities included a hamburger cooking demonstration to demonstrate proper cooking temperatures as well as safe food handling techniques. Other activities performed by the Environmental Health Division include responding to consumer complaints, investigation of cases of food-borne illness, there have been “180” cases in Sacramento County as of the end September of this year, evaluation of plans for new food facilities, as well as the granting of permits for these new food facilities (http://www. accounty. net/pdf/EMD-2004-10_Update. pdf, p. 4). Moreover, the Environmental Health Division continues to collect fees for their services and proudly distinguishes qualifying retail food facilities with their “Award of Excellence” for food safety. Last year, ninety-three area establishments were the recipients of this award. Future Needs The Food Safety and Protection Program is a growing program. As the number of food facilities in the Sacramento area increase, so do the needs of the program.

Some of the future needs of the program include an increase in the number of employees for the program, improved outreach programs, software program to improve inspections and inspection reports, and an implementation of a restaurant grading system. The first need of the program is an increase in the number of employees. With only 27 employees who actually do work under the Food Safety and Protection Program, the job of inspecting 6,000 food facilities plus other required tasks is certainly overwhelming. One might think, “Why don’t they just go ahead and hire more people? Working for the EHD not only requires a college degree but employees must also obtain certification deeming themselves Registered Environmental Health Specialists. Now one might think “What is a Registered Environmental Health Specialist? ” To answer the above question, the program needs to create an awareness of the position. This leads us to the second need of the program. The Food Safety and Protection program is in need of an improved outreach program. Up until finding out what personnel qualifications were needed, we did not know what a Registered Environmental Health Specialist was.

More concentrated efforts in outreach programs that introduce and educate people about the validity of their profession may generate more interest in the academic setting thus creating more potential professionals. Another need of the program involves a software program to improve inspections and inspection reports. This program needs to make the change from hand-written reports to typed reports. Going from hand-written to automation would make it much easier for people to read and understand the reports. The final future need of the Food Safety and Protection Program is to implement a restaurant grading system.

The restaurant grading system would provide to customers knowledge of where the restaurant stands in terms of food safety compliance. According to June Livingston, “The restaurants would be given a grade ranging from A-F. “A” of course being the highest grade to be received and “F” the lowest. A grade of “C”, would mean that the restaurant meets minimum compliance requirements” (personal communication, October 27, 2004). The program is still working on the grading system in terms of how it will work and getting legislation to approve the system. Changes to the Program

The Food Safety and Protection Program is an extremely successful program under the Environmental Management Department. For 27 employees to be able to inspect 6,000 food facilities is an incredible feat. However, with their measured success, there is some room for improvement. If we were administrators of the program there are a few things that we would do differently. One of the changes that we would make is to the outreach programs. Despite the fact that one of the goals of the program is to have more outreach programs, there is something that we would like to add.

In addition to having more outreach programs, we would have the programs target people as early as high school. The outreach should also be targeted at people in colleges and universities. By doing this, a larger audience of people would become knowledgeable of the profession and quite possibly decide to take the path to becoming a Registered Environmental Health Specialist. Another change would be to hire on more employees. With more employees, more work can be done and the current practice of multi-tasking would cease to exist.

More employees will allow for more inspections of food facilities thus reducing risk to the public. Increasing inspections of food facilities from annually/biannually to quarterly is another change that we would make as administrators. Food facilities currently undergo one, maybe two inspections a year. Every day new discoveries are made in terms of proper food handling, food-borne illnesses and much more. With these new discoveries, it would be particularly helpful and beneficial that inspections be made on a quarterly basis.

Also, more frequent inspections would encourage food facilities to really meet compliance and go above and beyond what is needed for food safety. The final change that we would make to the program is to improve inspection report legibility and visibility. If one were to take a look at an actual inspection report and read the comments written, it usually is difficult to read. We would make the inspection reports typed so that everyone would be able to read exactly what was found at the inspection. We would also improve the visibility of the report.

Truth be told, not every food facility has their inspection report visible to the public. We would change this by requiring that establishments post the reports either by the cash register, the doors, in the waiting area if applicable or even by the bathrooms. We would further enforce this requirement by charging the facility a certain fee if the inspection report is not fully visible to the public. The addition of a fee for not having the report visible would not only create added revenue for the program, but it would also get the food facilities to comply more strongly in order to avoid getting fined.

With these reports visible, the public would have the ability to find out whether or not they are eating at a food safe establishment. References County of Sacramento Environmental Department Website. (2004). Award of Excellence in Food Safety. Retrieved November 12, 2004 from http://www. emd. saccounty. net/EH/EMDFoodSafetyAwards. htm County of Sacramento Environmental Department Website. (2004). California Uniform Retail Food Facilities Law (CURFFL). Retrieved November 3, 2004 from http://www. Emd. saccounty. net/pdf/CURFFL2004. pdf. County of Sacramento California Website. (2004). County

Organization Chart. Retrieved October 16, 2004 from http://www. saccounty. net/portal/about/docs/county-org-chart. pdf. County of Sacramento California Website. (2004). Food Safety Program, Retrieved November 12, 2004 from http://www. dhs. ca. gov/ps/fdb/HTML/Food/indexfoo. htm. County of Sacramento Environmental Department Website. (2004). Prioritized Inspection Frequency, Retrieved November 12, 2004 from http://www. emd. saccounty. net/Documents/Info/Bulletin0503 prioritized_inspection_frequency. pdf County of Sacramento Environmental Department Website. (2004). Update.

Retrieved October, 16, 2004 from http://www. saccounty. net/pdf/EMD-2004-10_Update. pdf. Sizer, F. , & Whitney, E. (2003). Food safety and food technology. In E. Howe, & J. Boyd (Eds. ), Nutrition: Concepts and controversies (pp. 509-556). Belmont,USA: Wadsworth/Thomson Learning. APPENDIX A: THE ORGANIZATION CHART [pic] Note. From “County of Sacramento California Website” http://www. saccounty. net/portal/about/docs/county-org-chart. pdf Copyright 2004 by County Executive. Reprinted with permission. APPENDIX B: ENVIRONMENTAL MANAGEMENT ORGANIZATION CHART Figure 1. The subdivisions within Environmental Management.

APPEDNDIX C: PROPOSAL Proposal This case study seeks to explore the Environmental Health Division within the Environmental Management Department of Sacramento County. Investigation in this agency will reveal how the County of Sacramento protects its residents and consumers from potential health hazards and illnesses originating from retail food facilities. Today, the average consumer rarely worries about the risk of dining out or “grabbing a bite”; however, factors such as improper storage, cooking and handling of foods or poor sanitation practices have the potential to create serious illness and even death.

This agency warrants investigation since food is one of man’s most basic and vital needs for survival. ———————– Management Plans Private School Inspections Land Use Evaluation Toxic Site Clean Up Well Monitoring Septic Tanks Recycled Water Industrial Storm water Program Risk Evaluation Accidental Release HazMat Land Use Incident Response Storage Tanks Business Plans Mold Information Lead Illness Investigation Tobacco Retailer Program Medical Waste Recreational Health Food Protection & Safety Education Water Protection Hazardous Materials Environmental Health Environmental Management

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