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L--vrK �NVIRQn vLo, Sjiq. #---?-c7SJ COUNTY PH ONMENTAL EALTH DIVIS' MASTERFILE R' 9D INFORMATION FORM{EH 00 59111evl.ad 01941} <br /> New EH Program/Existing Facility �I New EH PragramlNew Facility r Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FFFACILITY 10 # RECORD ID # <br /> Please Mark the Appropriate Deeoription and Speoify Se and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} _ `�cJ '. ,q <br /> ...d - <br /> -Grade A Dairy Grade 8 Dalry Milk Diapeo... N, bar of Canuinere in Muld-Need Unit <br /> FOOD PROGRAM (1600) <br /> 1 seating C.P..iry I Square Footage <br /> oage <br /> Restaurant Produce Stand Ice Plant <br /> I Dry Stange.0, 1 with Food PrepauOne Number of Unit. <br /> Commissar Vendin Machines <br /> Retail Market I SAu.ra Feet... 1 with Meet Market only I with Food Prep.mdon I Ory Good.only <br /> I Make I V.Wcle Type I Color I Rapbned—IfI UneaseFood Vehicle I I 1 t 1 <br /> Make t Vehinle Type 1 Calor I Reghvntion a I U...../ <br /> Mobile Food Unit i I I I 1 <br /> Temporary Food Facility Special Event <br /> Dote.or Operedom from m Dace.of onetime. ham to <br /> HAZARDOUS WASTE PROGRAM {2200) <br /> I <br /> Hazardous Waste Generator Tone generated per year <br /> Tiered Permit Facility C.I.gorin.11y e.mrodaed Categod..ay Eaernpt Permit by Rule <br /> HOUSING PROGRAM {2400) EMPLOYEE HOUSING {2700] <br /> I Numher of Unit. Number of 1... I Employee IHotel/Motel <br /> Jail or Exempt Institution aporo.lmaea Data.of 000upanoy to <br /> LIQUID WASTE PROGRAM {4200} <br /> Pum er Vehicle ' R.ghtr.aon ;r 1 U.....E I C....ity 1 venial.a <br /> Pumper Yard Package Treatment PChemical Toilets I Nunber of mate <br /> lan[ <br /> MEDICAL WASTE PROGRAM {4500} <br /> [S-m11 <br /> rimer Care Acute Care Skilled NursingLar a Generator <br /> Generator Transfer Station Limited Hauler Veterinary Clinic <br /> ommon Stora a Facilityi t-10 generator. i 11 -so gener.Ior. i >so........... <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area <br /> Number of Pooh/spm at Faniliry pod/Spa 10 A <br /> SITE MRIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Hat Waste Haz Mat Pipeline <br /> Other Lead Agency Site I Cel EPA-RWQCS i cal EPA-DE <br /> TSC I US PA <br /> 1 NPL Sir. 1 Water Gudiw Site 1 Other <br /> SOLID WASTE PROGRAM {4400) <br /> LCIA <br /> ndfdlTransfer Station A /Canner Waste SitLandfill Site Sludge/Ash Site Compost Facility Recuse Vehicles Number of uniteNumber or Unlhste Tire Facilit Process/Re. <br /> .I. Facflfty 0 cu yd <br /> VECTOR CONTROL PROGRAM {4000} <br /> Poultry Farm Meaimum Number of Bird. Kennel <br /> Fnrargenny Nodfrcemon for tide FACIUTY and/ter PROGRAM Dey Night <br /> CONTACT PERSON: ( ) ( ) <br /> Designated Enpleyee P Progrwn Dement A✓I�7 `� /_ Currant Statue Number of UnitsR ID/ O�n 1, <br /> ensue y .te avwwe y Data A.Jnounang ne au but Clarkew v}�tv tl_te llV ` ate <br />