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T ^' UNTY PHS-ENVIRONMENTAL HEALTH DPJ&N MASTERFILEJ&ORD INFORMATION FORM (EH 00 590tevised 6194)} <br /> New EH Program/Existing Facility New EH Program/New Faa1fly Dote <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> FACILITY ID # RECORD ID # <br /> Please Mark the Appropriate Description and Specifyto or Number of Units.10.applioabw <br /> DAIRY PROGRAM {2000} <br /> Greda A Dairy Grade B Dairy Milk Dispemwr Number of Container in Multi-Heed Unit <br /> FOOD PROGRAM {1 600} <br /> I <br /> Restaurant Settling Capacity I Square Footage Produce Stand Ice Plant <br /> ' <br /> 1 <br /> 1 with Food Preparation Number of Unit.Dry storages nmly Verdin Machines <br /> Commissar <br /> I S,w—FootageI with Mwnt Mnrkwt only I with Food Prwoaradon I Dry Goods only <br /> Retail Market <br /> Mnkw ; Vehicle Type ; Color ; Registration A i Unease A <br /> Food Vehicle <br /> 1 Mnkw ; VCol.,liele Types ' Cor i Registration d i Uce—A <br /> Mobile Food Unit I <br /> 1 1 t I t <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} 014 22 <br /> I Ton.generated par year ---/ l 5 ! <br /> [Hazardous Waste Generator t�1 E <br /> Categorically authorized Categorically Exempt Permit by Rule <br /> Tiered Permit Facility i <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Ut»ta LE <br /> Employee. Dairy Employee Housing I <br /> Hotei/Motel <br /> ta Dete.of Occupancy <br /> Jail or Exempt Institution ::� to <br /> LIQUID WASTE PROGRAM {4200} <br /> I Rwgi.vtttion A 1 Ucernw A I C.pwcity I Vehicle A <br /> Pum er Vehicle <br /> Number of Units <br /> Pum er Yard Package Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> i <br /> Priynary Care Acute Care Skilled Nursing Large Generator , <br /> Shall Generator Transfer Station Limited Hauler Veterinary Clinic <br /> I <br /> 1 2•10 generators 1 7-60 generators >60 generators <br /> Common StorageFacility <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Spa Out of Service Pool/Spa Natural Bathing <br /> Number of Poola/Spae at Facility Pool/Spa ID if -- I <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pi aline <br /> 1. <br /> 1 Cd EPA-RWQC8 1 Cal EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> I NPL Site I Water auality,Sita 1 Other I <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Ao/Cannery Waste Site <br /> Number of Urns II <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> t <br /> Number,of Urns <br /> Waste Tire Facilit Process/Recycle Facilit <br /> Dum sters >20 cu yd j <br /> VECTOR CONTROL PROGRAM {4000} <br /> Kennel <br /> Maximcm Number of Birds <br /> Poultry Farm � <br /> Enwrgency Notification for this FACtUTY anti/or PROGRAM Drty Night <br /> CONTACT PERSON: I I <br /> Deigmyee A Program Element A Cuffs"Solar Number of Units EPAnID A <br /> t s <br /> ate <br /> Received by ate Reviewed by re tut Clark ate <br /> Y <br />