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s4J COUNTY PHS-ENVIRONMENTAL HEALTH IV MASTERFILE RD INFORMATION FORM{EH 00 59(Revited 6/9411} <br /> New EH Program/Existing Focility 11 New EH Program/New Facility Datej <br /> SHACEO SECTIONS FOR LOCAL USE QNLY <br /> FACILITY ID # RECORD ID # <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} <br /> Grade A Dairy Grade B Dairy Milk Dispenser Number of Containers in Multi-Head Unit <br /> FooD PROGRAM {16001 <br /> I Senting Capacity I Savare Footaoe Produce and Ice Plant f <br /> ' Restaurant <br /> I Ory Smrego only I will,Food P,epnmtion Number of Unita <br /> Commissar Vendin Machines <br /> I Srhlnm Footnpe I will,Mont Mniket only I with Food Preparation I Dry Goode only <br /> Retail Market f 1 —4 <br /> Make I Vehicle Type I Color ' Regiatrnllon X ' Uaems X <br /> Food Vehicle I I h i I <br /> I <br /> Make I Vehicle Type ' Color I Registration X i Ucense X i <br /> Mobile Food Unit I I I I <br /> i <br /> Temporary Food Facility Special Event <br /> Deter of Operation from to Dntsa of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> I Tons generated per year I. <br /> Hazardous Waste Generator <br /> Categorically authorized Categorically Exempt Permit by Rude <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> r <br /> I Number of Unita Number of 6nployses Dwiry Employee Housing <br /> [FHtelotelApproaimeta Oetee of Occupancy <br /> xempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> I Rggistrndon A I Ucenso X I Capacity i Vehicle X <br /> Pumper Vehicle I <br /> Number of Unita <br /> Pumper Yard Package Treatment Plant Chemical Toilets , <br /> MEDICAL WASTE PROGRAM {45500} <br /> Primer Care Acute Care Skilled Nursinga Lar Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 2-10 generators 11-50 generators >60 generetora <br /> Common Storage Facility <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 /> I <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental AssessmentUSTICAP Local Haz Waste TH., Mat Pipeline <br /> 1 Cal EPA-RW QCS 1 Cal EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> I NPL Site I Water Quality Site I Other <br /> SOUD WASTE PROGRAM {4400} <br /> I <br /> Landfill Transfer Station A jCa nery Waste Site <br /> Number of Unita <br /> CIA Landfill Site Sludge/Ash SiteCompost Facility Refuse Vehicles j <br /> Number of Unite II <br /> Waste Tire Facili Process/Recycle Facility Dum eters >20 cu yd <br /> VECTOR CONTROL PROGRAM {4000} e <br /> Mn:im,nn,Number of Bird! <br /> Farm L-' �-f 17 Kennel l <br /> Poultry fr/ or <br /> Finergoncy Notification for this FACILITY and/or PROGRAM Day Night <br /> CONTACT PERSON: ( { <br /> ED6,,qn",1,dyes 909 Program Element 945- Current Status Number of Units EPA ID X <br /> Date Rav,ewed by Me cao nunq Office ata nit eta tot [a eta <br />