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Si COUNTY PHS-ENVIRONMENTAL HEALTH DNISI MASTERFILE R INFORMATION FORM(EH 00 59(Rovised 61941) <br /> New EH Program/Existing Facility r New EN Progra fNew Faclity Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY U: Please Mak the Appropriate Descri e►of Units where applicable- <br /> DAIRY PROGRAM .{2000} <br /> Grade A Dairy Grade B Dairy <br /> Milk Dispenser Number of Containers In Multi-Heed Unit <br /> FOOD PROGRAM {1 6001 <br /> I Seating Capacity I Square Footage Produce Stand =Flce Plant <br /> ' Restaurant <br /> I Dry Storage only I with Food Preparation Vendina Machines Number of Units <br /> Commissar <br /> I Square Footage I with Meat Market only I with Food Preparation I Dry Goods only <br /> Retail Market <br /> I Registration s 1 Uoenw s <br /> I Make 1 Vslicle Type 1 1 Color Re 1 gi 1 <br /> Food Vehicle I 1 <br /> 1I Color I Registration x 1 Ucen+e+1 <br /> I Make 1 <br /> Vehicle Type 1 1 1 <br /> [Mob=ii1eFooLdUnit I <br /> Temporary Food Facility Special Event <br /> Dates of Operation from <br /> to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tons generated per year <br /> Hazardous Waste Generator I <br /> I Categorically authorized Categorically Exempt 1 Permit by Rule - <br /> Tiered Permit Facility 1 <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Units Number of Employees 11 <br /> Dairy Employes Housing <br /> HotellMotel <br /> Approximate Dates of Occupancy <br /> to <br /> Jail or Exempt Institution <br /> Liam WASTE PROGRAM {4200} <br /> 1 Registration# <br /> I Ucense# 1 Capacity I Vehicle <br /> Pumper Vehicle 1 <br /> 1 Number of UnitsPum er Yard Parka a Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Larne Generator <br /> Small Generator <br /> Transfer Station Limited Hauler Veterinary Clinic <br /> 1 I 11-60 generators >60 generators <br /> 1 2.10 generators 1 <br /> Common Storage Facility <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool <br /> spa Out of Service Fool S a Natural Batlun Area <br /> ID+r <br /> Number of Poole pod/spe Poole/Spee et Facility <br /> SrrE MMGATION PROGRAM {2900} <br /> Environmental Assessment USTICAP Local Haz Waste Haz Mat Pipeline <br /> 1 Cal EPA-RWQCB I Cal EPA-OTSC 1 US-EPA <br /> Other Lead Agency Site I otin.r <br /> 1 NPL Site 1 Water Quality Site <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill <br /> Transfer Station A /Canner Waste Site <br /> Number of Units <br /> CIA Landfill Site Sludge/Ash Site Compost Faclity Refuse Vehicles <br /> Number of Unit <br /> Waste Tire FacilityProcess/Rec cle Facility Dum stets/>20 cu d <br /> VECTOR CONTROL PROGRAM {4000} �Z <br /> Maximum Number of Birds Kennel <br /> Poultry Farm <br /> Day Night <br /> Emergency Notification for this FACILITY and/or PROGRAM <br /> I <br /> CONTACT PERSON: wv, <br /> 8emerrt rY <br /> Designated Employ..ar Pro9rush Current8tetw Mn�bsr <br /> a <br /> EPA 16 <br />