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SJ COU`JTY P"S- EN IRONMENTALHEA TH ISIO MASTERFILE RE( INFORMATION FORM {EH 00 59(RevLed arca*} <br /> New EH Program/Existing Facility C New EH ProgramlNew Facility Uete <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY ID # " RECORD ID # <br /> Please Mark the Appropriate Description and Specify Size endlor Number of Units where applioeble: <br /> DAIRY PROGRAM 20001 <br /> Q+eda A Dairy Grade 6 Dairy Milk Dispenser Nwnber of Containers In Multi-Head Unit <br /> FOOD PROGRAM {I 6001 <br /> I Seatiop Capacity 1 Square Footage <br /> ' Restaurant Produce Stand Ice Plant <br /> I Dry Storage only I will;Food Preparndon Number of Unit. <br /> Commissar Vendin Machines <br /> I <br /> Retail Market Square Footnge I with Meet Market only I with Food Preparadon I Dry Good.or 71-7 <br /> Make I Vehicle Type I Color I Rletration 0 e t Uo.n..! <br /> Foal Vehicle 1 1 I I g I <br /> Mobile Fond Unit Make vehicle Tyr. color Registration r 1 Uaaa..s <br /> r <br /> r <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tons generated per year <br /> Hazardous Waste Generator <br /> Categoricarty authorized Categorically Exempt F Permit by Rut <br /> Tiered permit Facilit <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING (2700) <br /> Hotel/Motel I Number of Unit. Number of Employee. Daily Employee Housing <br /> Jaii or Exempt Institution Approximate Date*of Ocoup.noy, to <br /> LIQUID WASTE PROGRAM (4200) <br /> Pumper <br /> I Registration A r Ucense p 1 Cepaclty 1 Vehicle/ <br /> Vehicle <br /> Pumper Yard Package Treatment Plant Chemical Toilets Number of Units <br /> MEDICAL WASTE PROGRAM {4500) <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Shall Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility <br /> 2-10 ganerators 11 -60 genereton >60 generator. <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Spa Out of Service Pool/Spa Natural Bathina Area <br /> Ntmrber of PoolslSpne at Facility Pnollspn 1D A - - <br /> - ------------ <br /> SrrE Mme.AnoN PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> I Cal EPA Rw QCR t Cat EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> i NPL Site 1 Water Ouallty Site 1 Other <br /> SOLID WASTE PROGRAMA {4400} 1 <br /> Landfill Transfer Station AQ/Cannery AQ/CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles N;anher of Units <br /> Waste Tire Facility Ptocess/Rec cle Facility Dum eters >20 cu yd Number of Unit. <br /> VECTOR CONTROL PROGRAM {4000) <br /> Poultry Farm M..Imam Numb.,or Birds Kennel <br /> Ernergency Notiflcntion for this FACIUTY andlai PROGRAM Day Night <br /> CONTACT PERSON: ( ) ( } <br /> Designated Finployee it progtem Element'!ZT Currant"'etas Number of unit* I A'D <br /> Receivedy ate aviewe y ate &—' ccounung Offluo eta UnitClark _ ata nit Staff ate <br /> F" <br />