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�OU9VTY PHS-ENVIRONMENTAL HEALTH DlyaJON AMU) � Z�JI MpyTERFII "'CORD INFORMATION FORM {EH 00 59win,i.ad s/941} <br /> New EH Program/Existing Facility New EH ProgramiNew Facility Date <br /> SHADED SECTIONSFOR LOCAL USE ONLY <br /> FACILITY ID # o�?�� / RECORD ID # 5z),7 o54 <br /> l <br /> Please Mark the Appropriate Description and Specify Size erAlor Number of Units where applicable: <br /> DAIRY PROGRAM {2000} — 5-D-i 0— <br /> Grade A Dairy Grade B Dairy Milk Dispenser Number of Containers in Muld-Head Unit <br /> FOOD PROGRAM {1 6001 <br /> 1 Seating Capacity I Square Footeae Produce Stand Ice Plant <br /> Restaurant <br /> I Ory Storage only 1 with Ford Preperadon Vending Machines Number of Units <br /> Comfnissary 1 <br /> 1 <br /> 1 Srnmre Fnnmge I with Ment Mnrket onry with Food Preparadon I Ory Goode only <br /> Retail Market I <br /> Make I Vehicle Type I Colo Regivowilon S ; Ucarrw d <br /> Food Vehicle 1 1 f <br /> Make i Velticla Type ; Color I Registration A i Ucansa t: <br /> Mobile Food Unit 1 1 <br /> Fe,...,p-rary Food Facility Special Event <br /> of Operation from to Oates of Operation from to <br /> I <br /> _21--HAZARDOUS WASTE PROGRAM {2200} <br /> I Tons generated per year Z.rJ. --Z o <br /> Hazardous Waste Generator t ✓ �1 <br /> 1 Categorically authorized Categorically Exempt 1 Permit by Ride j <br /> Tiered Permit Facilityl l <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Units Number of Employees Dairy Employee Housing I <br /> Hotel/Motel <br /> Approximate Oates of occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> I Registration A 1 Ucansa t 1 Capacity 1 VoNcie f f <br /> Pumper Vehicle <br /> � Number of Units <br /> per Yard Packs a Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Lar a Generator <br /> Sinall Generator Transfer Station Limited Hauler Veterinary Clinic <br /> I11•fi0 enaretors <br /> Common Storage Facility 1 >SO genetetors <br /> I 2-to generators g I <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> ENu-bw <br /> Spa Out of Service Pool/Spa Natural-BathingArea <br /> of Pool$/Span at Facility - Pool/Spa IDA j <br /> SITE MmGAnoN PROGRAM {2900} <br /> Environmental Assessment USTICAP Local Haz Waste Haz Mat Pipeline <br /> I Cal EPA-RW QCS 1 Cal EPA-OTSC I US-EPA <br /> Other Lead Agency Site <br /> I NPL Site i Water Quality Site I 0that <br /> SOLID WASTE PROGRAM {4400} <br /> I <br /> Landfill Transfer Station Aa/Cannery Aa/CanneryWaste Site <br /> Number of Units <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> I <br /> Number of Units <br /> Waste Tire Facility Process/Recycle Facility__ Dum sters >20 cu yd i <br /> VECTOR CONTROL PROGRAM {4000} <br /> Maxm irnu Number of Birds <br /> Poultry Farm Kennel <br /> Emergency Notifiration for this FACIUTY arullor PROGRAM Dar Night <br /> CONTACT PERSON: I <br /> EA�—ved <br /> Employee A Program Element 4 � Curur of nits.27 <br /> 7N ) �.�ILate <br /> ca aintaig Office ate utCetk ate rtstaff <br /> Date vwwed by ate I <br />