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SJ,CO'J%ii PHS-ENVIRONMENTAL HEALTH DIVISIO MASTERFILE REQM INFORMATION FORM{EH 00 591Revised 8/941} <br /> New EH Program/Existing Facility New EH Program/New Facility Date <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> FACILITY ID # RECORD I0 # <br /> DAIRY PROGRAM {2000} Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> Grade A Dairy Grade 6 Dairy Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD PROGRAM {1 GOO} <br /> 1 Seating Capacity 1 Square Footage <br /> Restaurant Produce and Ice Plant <br /> I Dry Storage only I with Food Preparation Number of Units <br /> Commissary Vending Machines <br /> 1 Square Footage i with Meat Mnrket only 1 with Food Prepnrntlon I Dry Goods only <br /> Retail Market <br /> i Make i Vehicle Type i Color I Registration# ' License# <br /> Food Vehicle I I 1 1 1 <br /> i Make i Vehicle Type i Color i Registration# i License# <br /> Mobile Food Unit I 1 1 1 1 <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> ............. ......................................... <br /> 1 Tons generated per year <br /> Hazardous Waste Generator <br /> Tiered Permit Facilit Categorically authorized Categorically Exempt Permit by Rule <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700) <br /> I Number of Units Number of Employees Dairy Employee Housing <br /> LeApproximate Dates of Oocupnnoy l/Motel or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> Pum er Vehicle i Registration # I Ucense# I capacity I Vehicle# <br /> Pumper Yard Package Treatment Plant Chemical Toilets Number of Units <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursina Lar a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facilityj 2-10 generators 11-60 generators >60 generators <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area <br /> Number of Pools/Spas at Facility Pool/Spa ID.A <br /> .. <br /> SITE MMGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site 1 Cal EPA-RWQCB I Cal EPA-DTSC I US-EPA <br /> 1 NPL Site 1 Water Quality Site I Other <br /> SOLID WASTE PROGRAM {4400} <br /> _..... <br /> ...... ......... <br /> Landfill Transfer Station An/Cannery An/CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of Units <br /> Waste Tire Facility Process/Recycle Facility 2u12stere >20 cu yd Number of Units <br /> VECTOR CONTROL PROGRAM {4000} <br /> J[P=.ultryrm Maximum Number of Birds Kennel <br /> -rergancy Notification for this FACIUTY and/or PROGRAM Day Night <br /> TACT PERSON: ( ) ( ) <br /> d 6nployee it Pro11 gram El2ment Curront Status Number its SPA ID <br /> (73 <br /> Our Reviewed by... sta cooling roeate nit at," ata i. rxt to ate <br /> 4,r <br />