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MASTERFILE RE-, RD INFORMATION FORM{EH 00 59tRevised 61941} <br /> SJ CoUNfY PHS-ENVIRONMENTAL HEALTH DIVIS <br /> New EH Program/Existing Focility New EH ProgramiNew Facility <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> _ F_ _A_C_1L_ITY 1D # 007(o93 RECORD ID # I®4U �) <br /> Please Mark the Appropriate Description and Specify Size IIXW r Number of Units where applicable: <br /> DAIRY PROGRAM {2000) <br /> Grado A Dairy Grnde B Dairy Milk Dispomor Ntmber of containers in Multi-Heed Unit <br /> FOOD PROGRAM {1 GOO} <br /> I Senting Caoacity I Square Footage Produce Stand I Ice Plant <br /> Restaurant <br /> I Ory Storages nrdy I with Food PrePm^tic^ Verdin Machines Number of Vnib <br /> Commissar <br /> 1 Srpmrw Footnoe 1 with Mont Mnrkot nrdy I with Food Prop—do. I Dry Goods only 1 <br /> Retail Market <br /> I Makro I Veidcle Typo 1 Color tiegistradon X 1 uoense X <br /> F-j-dVehicle1M^kw I Vehicle Type I Color I Rgistration X 1 Ucense X <br /> Food Unit I I I 1 <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of operation from to I <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tons generated per year <br /> Hazardous Waste Generator <br /> t <br /> Categorically authorized I categorically Exempt Permit by Rtda � <br /> Tiered Permit Facility 1 <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Units Number of Employees Dairy Employee Housing �I <br /> HoteIiMotel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution tO <br /> LIQUID WASTE PROGRAM {4200} <br /> I Regist-don X I Ucensw X I Capacity I Vehicie X <br /> Pum er Vehicle <br /> Number of Units <br /> Pumper Yard Packs a Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 1I 11-60 generators I <br /> I 2-10 generators >60 generators I 1 <br /> Common Storage Facility <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Spa Out of Service Pool/Spa Natural Bathin Area <br /> Number of PoolslSptrs at Facility <br /> Pod/Spa ID X- <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> I Cat EPA.RW QCB 1 Cd EPA.OTSC 1 US•EPA <br /> Other Lead Agency Site <br /> I NPL Site I Water Duality Site I Other <br /> SOLID WASTE PROGRAM {4400} <br /> { <br /> Landfill Transfer Station AulCannery Waste Site I <br /> Number of Units <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> i <br /> Number of Units J <br /> Waste Tire Facility Process/Recycle Facilit Dum stern >20 cu yd f <br /> VECTOR CONTROL PROGRAM {4000} <br /> Maximum Number of Birds Kennel <br /> Poultry Farm 1 <br /> Finorgency Notiticalion for this FACIUTY andlor PROGRAM Owv Night <br /> CONTACT PERSON: l t <br /> Designated Employee X I Program Bement X Currant Status Number of Unita EPA 10 s <br /> I <br /> Accounting Office Dam tt Carsp <br /> Roved by Onto Rvewed by ate s <br />