Laserfiche WebLink
Si COUNTY PHS-ENVIRONMENTAL HEALTH DIVISION MASTERFILE RECOR RMATION FORM{EH 00 69lRevlsed 8/841} <br /> 10 <br /> Cil <br /> New EH PromemlNew Facility Date <br /> aiN /Existing Facilky <br /> E <br /> CTIONS FOR LOCAL USE ONLY <br /> SHADED <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: -- <br /> DAIRY PROGRAM {2000} <br /> Grade A Deity .Grade a Dairy <br /> Grade <br /> Dispenser Number of Containers in Multi-Need Unit <br /> FOOD PROGRAM {1 6001 <br /> I Sesting Capacity I square Footage Produce Stand Leo Plant <br /> .Restaurant Number of Unit <br /> I Dry storage only I with Food Preparation Vendin Machines <br /> Commissar <br /> 1 with Meet Market only 1 with Food Preparation I Dry Goods only <br /> 1 Square Footage - <br /> Retail MarketI Uoensa# <br /> Make <br /> I Vehicle Type I Color I Registration# 1 <br /> I I I I <br /> Food Vehicle 1 <br /> 1I Color I Registration Jr I IJoense# <br /> Make 1 Vehicle Type 1 I 1 <br /> Mobile Food Unit <br /> Special Event <br /> Temporary Food Facility from to Dates of operation from to <br /> Dates of Operation <br /> HAZARDOUS WASTE PROGRAM {2200} ::::::: <br /> I Tons generated per year <br /> Hazardous Waste Generator Categorically Exempt Permit by Rule <br /> I Categorically authorized <br /> I <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> Number of 6nployeea Dairy Employee Housing <br /> 1 Number of Units <br /> Hotel/Motel <br /> Approximate Dates of Occupancy to <br /> Jail or Exempt Institution <br /> LIQUID WASTE PROGRAM {4200} <br /> 1 Capacity i Vehicle# <br /> 1 Registration# I License# . <br /> Pum er Vehicle ------�7 Number of Units <br /> Pumper Yard Package Treatment Plant I Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care <br /> Acute Care Skilled Nursin Larne Generator <br /> Small Generator Transfer Station <br /> Limited Hauler Veterinary Clinic <br /> 1 1 t 1-So generators <br /> 1 2-10 generators I <br /> PA <br /> Common Storage Facility <br /> RECREATIONAL HEALTH PROGRAM {5600) ,(] <br /> Out of Seri c Poo S a "a 1 <br /> Pool of <br /> Number of Pools/Spas at Facility ....�... <br /> �.. <br /> ,....PUBLIC H •�..�. <br /> SITE MMGAT10N PROGRAM {2900} FA <br /> UST/CAP Local Haz Waste �az4Tdi <br /> Environmental Assessment I Cel EPA-DTSC I US-EPA <br /> 1 Cal EPA-RWOCB <br /> Other Lead Agency Site I <br /> I Water Quality Site I other <br /> I NPL Site <br /> Sill <br /> WASTE PROGRAM {4400} <br /> Landfill Transfer Station Number of Unite <br /> Slud 3/Ash Site o cility Refuse Vehicles <br /> CIA Landfill Site 9 Number of Units <br /> •" <br /> Oc <br /> u <br /> d <br /> Waste Tire FacilityProcesslRecoleFa %. m <br /> ••'• p,� <br /> VECTOR CONTROL PROGRAM {40 0} <br /> Maximum Number-f-8ds Kennel <br /> Poultry Farm Day Night <br /> ergency Notification for this FACILITY and/or PROGRAM ` '�'y� <br /> CONTACT PERSON: `/.t'�SIF !/Sr��t <br /> .::.Gat ;1'antdoy?+a;�.::::•.........:::::::::....... ::::::>;::;:::................ ... <br /> snared............:::.....:::::.�::.-:::................. ....:.............................:.......::.:::......... ....,:.,.:....... ............... <br /> .. <br /> V <br /> : <br />