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Si COUNTY PHS-ENVIRONMENTAL HEALTH ONISI MASTERFILE RE' 0 INFORMATION FORM(EH 00 591Rev1eed 6/04)} <br /> N En ProgirruntExisting Facility Now EH Prong /N Facility 1 Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> A <br /> FACILITY ID # <br /> `9-116 RECORD ID # <br /> Pleaea Mark the Appropriate Description and Sp cifp Six-andlor Num of Unita where applicable: <br /> _DAIRY PROGRAM (2000) � ' 5D <br /> Grade A Dairy Grade B Dairy <br /> Milk Dispe...I Number of Container.in Multi-Heed Unit <br /> _FOOD PROGRAM {1600} <br /> I Stalin,Cap..[,, 1 Sous.Epping. Produce Stand Ice Plant <br /> R t ur t <br /> 1 with Food Prepenta— Number of Units <br /> 1 or,slomq.mar Vendin Machines <br /> Commissar <br /> I S.pme Fpot.ge I with Meet Market My <br /> 1 with Food Preperetlon I Dry Good.only <br /> Retail Market <br /> I M.ke I Vehicle Type color ; IRegle nnihm, Uaanee, <br /> Food Vehicle <br /> 1 M.ke I Ve1nN.Trp. I color I Rea bed°n, Uo.n.. , <br /> Moble Food Unit 1 I 1 <br /> Temporary Food Facility Special Event <br /> oaua of Operatlon bora m Data.of operation from t0 <br /> _HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tone gen°rnted per Veer <br /> Hazardous Waste Generator <br /> Gd.g.hildly suthorbed Cataporlpnlly Exempt / Penult by RN. <br /> Tiered Permit Faclit 1 <br /> HOUSING PROGRAM (2400) _ EMPLOYEE HOUSING {2700} <br /> 1Number of UNN Number or Employee. Dairy Employee Houelnq <br /> Hotel/Motel <br /> Ap,ronimate Date.of oc.upnncr <br /> Jail or Exempt Institution to <br /> _ LIOUID WASTE PROGRAM {42001 <br /> I RepH,rntlon A I Ucenae, I CePeciry 1 VeNale, <br /> Pum er Vehicle <br /> 1 Number of units Pum er Yard Package Treatment Plant Chemical Toilets 1 <br /> MEDICAL WASTE PROGRAM {4500} <br /> Prima' Skilled Care Acute Care Nursin Lar a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facilityi 2-l0,sion.tore i 11-50,.n...to,. i >So genera m. <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Pool spa Out of Service Pool/Spa Natural Bathing Area <br /> Nunberor,00l./Spas at Facility Pod/Spa ID IF <br /> SITE MITIGATION PROGRAM (2900) <br /> Environmental Assessment I USTICAP Local Hat Waste Haz Mat Pipeline <br /> 1 CA EPA-RWGCB I CA EPA-UTSC 1 US EPA <br /> Other Lead Agency Site <br /> I NPL Site I water ounliry site I Other <br /> $OLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station An/Cannery An/CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number or Gait. <br /> Waste Tire Facilint, Process/Rec cle Facilitv Dum stere >20 cu d Number a!Units <br /> VECTOR CONTROL PROGRAM {4000) <br /> Poultry Farm Minim en Number of Bbd. Kennel <br /> Emergen°y Nod6ceUon for fig.FACILITY end/or PROGRAM S Do, Mph, <br /> CONTACT PERSON: f ZZ7 _9 ( ) <br /> Dwigne,.d Employee, pro".Element p !' C.n rt pt.e Numb.r of Unit EPA ID I / / 3 <br /> �O 9 <br /> Released y .,. evlewe y —lrn' c°ounanq me she RLL ate in toD.I. <br />