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SJ COON rY PHS-ENVIRONMENTAL HEALTH DIVISI MASTFRFII F:'Aft INFORMATION FORM{EH 00 691Ftevisod 6/94)} <br /> 1 Z:Z <br /> New EH Program/Existing Fa:,7flty�D[ New EH Progrand-']' e Facility Date 6 <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> X X <br /> . .. ....... .. . <br /> .7� <br /> F D: <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applio"-. <br /> DAIRY PROGRAM 120001 <br /> Grade A Dairy I Grade B Dairy Milk Dispenser Number of Containers In Multi-Head Unit <br /> FOOD PROGRAM {1 600} <br /> 1 Seating Capacity I Square Footage <br /> Restaurant I Produce Stand Ice Plant <br /> Commissary 1 Dry Storage only ti <br /> with Food Preparaon Vndina Machines Number of Units <br /> rRetail Market Square Footage 1 with Meat Market only I with Food Preparation I Dry Goods only <br /> Make 1 Vehicle Type I Color 1 Registration# I Uoenss# <br /> Fond Vehicle <br /> Make I Vehicle Type I Color 1 Registration# 1 Ucense* <br /> Mobile Food Unit <br /> E.-.Temporary Food Facility Special Event <br /> Dates <br /> P.7 10-pr ration from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM 122001 <br /> Tons generated per year <br /> Hazardous Waste Generator <br /> Tiered Permit Facility Categorically authorized Categorically Exempt I Permit by Rule <br /> HOUSING PROGRAM 124001 EMPLOYEE HOUSING {2700} <br /> I Number of UnitsNumber of Employees F�ployes Housing <br /> Hotel Motel <br /> M-1 <br /> JailJ Jail or Exempt Approximate Dates of Occupancy to <br /> or Em mpt Institution <br /> LIQUID WASTE PROGRAM (4200} <br /> 1 Registration# 1 Ucense# 1Capacity I Vehicle# <br /> Pum er Vehicle . 1 <br /> Pumper Yard =1 Package Treatment Plant IF Chemical Toilets Number of Units <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Larae Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility 2-10 generators 11-60 generators >60 generators <br /> RECREATIONAL HEALTH PROGRAM {3600) <br /> Pool spa Out of Service Poolfta Natural Bathing Area <br /> Number E.1 PE..1].lSpas at Facility <br /> ................ ...... <br /> SITE MITIGATION PROGRAM {2900} ,W <br /> r <br /> Environmental Assessment UST/CAP Local Haz Waste az Mat Pipeline <br /> Other Lead Agency Site <br /> Cal EPA RWQCB Cal EPA-OTSC <br /> A 111"� <br /> NPL Site 1 Water Quality Site <br /> i,�)i INTY <br /> SOLID WASTE PROGRAM {4400} q-tf.Lf I j13LIC HEALTH SERVICES <br /> C— <br /> Landfill Transfer Station Aa/Cannery Waste site <br /> CIA Landfill Site Sludge/Ash Site Compost Focaity Refuse Vehicles Number of Units <br /> ................ <br /> Number of Units <br /> Waste Tire Facility Process/Recycl Dumpsters >20 cu d y <br /> a Facility <br /> VECTOR CONTROL PROGRAM {4000} <br /> Poultry Maximum Number of Birds Kennel V <br /> Emergency Notification,for this FACILITY and/or PROGRAM Day Night <br /> CONTACT PERSON.- <br /> .. ......... ... ......... <br /> X <br /> .... ....... <br /> -::X.. ::.........1. <br /> .... ........ <br />