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f SJ CANTY PHS-ENVIRONMENTAL HEALT MASTERFIL RD INFORMATION FORM{EH 00 59tRevised S/gal} <br /> New EH 41 <br /> Program/Existing Facility New EH Program/New Facility t Date 2 <br /> SHADED SECT/ONS FOR LOCAL USEVNLY <br /> FACILITY ID # / RECORD ID # SD <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Unita 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 {1 GOO} <br /> 1 Senting Capacity I Square Footage Produce Stand Ice Plant <br /> _ Restaurant r t <br /> Number of Units <br /> i Dry storage only I with Food Preparation Vending Machines <br /> Commissary I I <br /> i Square Footage 1 with Meat Market only I with Food Preparation I Dry Goods only <br /> Retail Market <br /> I Make I Vehicle Type Color Registration# ; Ucense# <br /> [T-7odWhicle I 1 <br /> I i i I 1 <br /> Make I Vehicle Type i Color ; Registration# license# <br /> Mobile Food Unit I I <br /> I I t I 1 <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tons generated per year <br /> Hazardous Waste Generator <br /> Categorically authorized Categorically Exempt Permit by Rule <br /> ;a <br /> Tiered Permit FacilityI <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Units Number of Employees Dalry Employee Housing <br /> FHtelotel <br /> Approximate Dates of Occupancy <br /> xempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> I Registration# I Ucense# I Capacity i Vehicle# <br /> Puin er Vehicle <br /> � Number of Units <br /> Punt er Yard Package Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Small Generator Transfer Stationinvited Hauler Veterinary Clinic <br /> I 2-10 generators 1 I I-60 generators >60 generators <br /> Common Storage Facility <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> LEO., <br /> S a Out of Service Pool/S a Natural Bathin Areaf Pools/Spas at Facility Pool/Spa ID# <br /> SITE MmGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> I Cel EPA-RWQCB I Cal EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Site 1 Water Quality Site I Other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Aq/Cannery A /CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost a ility c B Number of Unite <br /> Waste Tire Facility Process/Recycle FacilitXk ya Dum sters > 0 cu yd Number of Units <br /> VECTOR CONTROL PROGRAM {4000} <br /> r=-.Uluy Farm <br /> Maximum Number of Birds Kennel <br /> Emergency Notification for this FACIUTY and/or PROGRAM _ Day Night <br /> CONTACT PERSON: t <br /> `J 4J t <br /> 'Nnber bUnita: <br /> ated nplomtatt� <br /> rre <br /> CurrenS -K7 <br /> v. <br /> ReceatReviewedy ate 000unting ice Date t eeta EPA(D <br /> t staffets. <br /> cz�3f a� i txt <br />