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Si COUNVVII <br /> PHS-ENVIRONMENTALL H LTH DIVISIO <br /> MASTERFILE RE( y INFORMATION FORM {FH 00 591Real.ed s/sal} <br /> New EH Program/Existing Facility Now EH Program/New Foo Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY ID #. RECORD ID # <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {ZOOO} <br /> Grade P Dairy Grade B Dalry Milk Diapever Number of Containers in Mud Head Unit <br /> FOOD PROGRAM {1600} <br /> Restaurant 1 Senting connect, I Sq..,.Footage Produce Stand Ice Plant <br /> Commissar I Dry Storage only I with Food P,epameon Number of Units <br /> Vending Machines <br /> I SAuere <br /> Retail Market Footage I warnti <br /> with Meat Market only I with Food Prapon I Dry Good..4 <br /> f Make I vehicle T,q a I Colo, I Registration # I Unen.a I <br /> Food Vehicle I 1 r 1 I <br /> 1 Make I Vallole Type 1 Eclat 1 Reglatrnnno # I U.....I <br /> Mobile Food Unit I I 1 1 <br /> Temporary Foad Facility Special Event <br /> Dated or ope,anon r,pm m Data.or oparanon from m <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> Hazardous Waste Generator i Tons generated per year - <br /> Tiered Permit Facilityi Cntsgprio.11,enthod.ed categorically Exempt i Pamir by Rae <br /> HOUSING PROGRAM {2400) EMPLOYEE HOUSING {2700} <br /> I Number at Unita Number or Employees Dalry Employee Housing <br /> Hotel/Motel <br /> Approximate Dotes or 000upeney <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> I Regt....tin. A I Ucp <br /> eme # 1 capacity I vend.# <br /> Pum er Vehicle <br /> 1 Number at Units <br /> Punt er Yard Packs a Treatment Plant Chemical Toilets 1 <br /> MEDICAL WASTE PROGRAM {4500} <br /> L <br /> rCare Acute Care Skilled Nursin Ler a Generator <br /> Generator Transfer Station Limited Hauler Veterinary Clinic <br /> mon Stora a Facility <br /> j 2.io ascension, i t 1 -so generators i >So gane,ato,. <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool <br /> Spa Out of Service Pool S a Natural Bathing Area <br /> Nanber or Poolslapns It Fnainty Pool/Spa ID# <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> I Cel EPA-RWOCB I Cel EPA-DTSC I USEPA <br /> Other Lead Agency Site <br /> 1 NPL Site I Water Ouallty,site I Other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Arl/Cannery A /CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Numb.,of Units <br /> Waste Tire Facility Process/Rec cla Facility Dunt stere >20 cu yd Number of Units <br /> VECTOR CONTROL PROGRAM {4000) <br /> Ma.linm uNumber.(Bird, Kennel <br /> Poultry Ferm <br /> Emerge.,Nonfipation rot this FACILITY end/or PROGRAM Oxy Night <br /> CONTACT PERSON: <br /> E <br /> ned # Proprom Bement I-"- Curent Statue Nmnho,or Unita <br /> ate y ice Dow Unit Clork veto Unit <br /> D Wto.. <br />