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IJ C0.I2'r2:Y PHS-ENVIRONMENTAL HEALTH DIVISIr MASTERFILE RE I INFORMATION FORM (EH 00 591Revlsed 6/941) <br /> IrNew EH Program/Existing Facility E_ New EH Program/New Facility ate 7- q'z4 <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> FACILITY ID # RECORD ID # <br /> DAIRY PROGRAM {2000} Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> Grade A Dairy G-d.B 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 Stand Ice Plant <br /> Commissar <br /> 1 Dry Storage onVendin Machines <br /> ly I with Food Preparation Number of Units <br /> I Squnre Footage I with Meat Market only I with Food Preparation I Dry Goode only <br /> Retail Market <br /> Make1 Vshlole Type I Color I Registration:r 1 License X <br /> Food Vehicle I 'FIC: 1 iY_i,t C Ic_ I JtLt� <br /> Make I Vehicle Type I Color I Registration J I License X <br /> Mobile Food Unit I I 1 1 I <br /> Temporary Food Facility Special Event <br /> Dates of Operatfon from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> Tons generated per year <br /> PHaa -a Waste Generator <br /> Categorically authorized Categorically Exempt Permit by Rule <br /> ermit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Units Number of Employees P` yea Housing <br /> Hotel/Motel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> Pumper Vehicle I Registration# 1 ucen.. a I Capacity r1j IRI IC <br /> Pumper Yard Package Treatment Plant Chemical Toilets 1 Number oEOMfdRONMENTAL HEALTH D1\/IS10'v <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursina Large 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 /> E,--o <br /> S a Out of Service Pool/S a Natural Bathin Area <br /> r of Pool./Spas at Facility Pool/Spa ID A <br /> SETE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site I Cal EPA-RWGCB I Cn1 EPA-DTSC 1 US-EPA <br /> 1 NPL Site 1 Water Duality Site I Other <br /> SOLID WASTE PROGRAM {4400} <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 Dunt eters >20 cu yd Number of Units <br /> VECTOR CONTROL PROGRAM {4000} { <br /> Maximum Nmnber of Birds ,VV• a 3 O <br /> =P,ullym O Ke tnel <br /> Emergency Notification for this FACWTY and/or <br /> PROGRAM �s T- Night <br /> CONTACT PERSON: 1f O ( ) J <br /> Designated Employee A ^-^'y ProgramElement q current Status Number of Units - EPA ID <br /> Received y Date eyrawe y Date coou1 Ong roe f ata n Clarke[e rrt to ate <br />