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SJOUNTY PHS •ENVIRONMENTAL HEALTH DIVIqjft 44ASTERFILE R D INFORMATION FORM(EH 00 59(Revieed 61941} <br /> New EH Program/Fxisting Facility New EH Program/New Facility Date ' <br /> SHADED SECTIONS FOR LOCAL USE ONLY /dJ ry p <br /> FACILITY ID # -s RECORD ID # r/% d! a �� <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} <br /> Goads A Dairy Crede B Otiry Milk Dispenser Number of Containers in Multi-Hand Unit <br /> FOOD PROGRAM {1 6001 <br /> I Seating Capacity I Square Footage Produce Siand Ice Plant <br /> Restaurant <br /> ' <br /> t <br /> Commissar Ory Storage only t with FinVendin Machines <br /> d P-pri—inn Number of Units <br /> 1 $ruoonrw Footnpe 1 with Mwot Mnrkwt only t with Food Prwonrndon 1 Dry Goods only f <br /> Retail Market <br /> Mak. Vehicle Type 1 Color t Ragistrnaon S I Uoense 9 <br /> rF--d Vehicle t 1 t <br /> i <br /> I Make ; Vehicle Type i Color ; Regtrtrwtion A ' Uaense ht <br /> Mobile Food Unit 1 <br /> f t 1 1 1 <br /> I <br /> Fe-porary Food Facility Special Event i <br /> of Operation at <br /> from to Owes of Operation from to I <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> I Tons generated per year j <br /> Hazardous Waste Generator I <br /> I1 <br /> Categorically authorized Categorically Exempt Permit by Rude I <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Units Ntanber of 6nphoyea9 Dairy Employee Housing l <br /> Hotel/Motel <br /> Approximate Oates of Occupancy , <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> 1 Registration N I Ucense A 1 Capacity t Vehicle f I <br /> Pumper Vehicle <br /> Ntsnber of Units <br /> Pum er Yard Package Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> i <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Shall Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 2-10 generatorst t-Go generators >6o generators f <br /> Common Storage Facility <br /> RECREATIONAL HEALTH PROGRAM {3000} <br /> Pool <br /> --Fs—.a Out of Service Pool/Spa Na 6athin Area <br /> Number of PoolslSpas at Facility Pod/Spa IDA _ -- <br /> SITE MIMIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> 1 Cal EPA-RWQCB I Cd EPA-OTSC I US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Site I Water QuaAty Site I Other j <br /> SOLID WASTE PROGRAM {4400} <br /> li <br /> Landfill Transfer Station a./rAnnpry Waste Site <br /> Number of Units <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Ii <br /> Number of UnitsWaste Tire Facilit Process/Recycle Facility Dum sters >ZO cu yd <br /> VECTOR CONTROL PROGRAM {4000} <br /> Maximow Number of Birds <br /> Farm Kennel <br /> Poultry <br /> Ennergency Notifi—lion for this FACIUTY nowt/or PROGRAM Day Night <br /> CONTACT PERSON: �il/ } -33&C) ( I <br /> =Employ.0,1M2? Program Bement A ��" Current Status Number of Units EPA ID 0e Rswewed by ale ccounonq Oltice ate nit Clerk ata nt te ere <br /> t � <br />