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C ITT 11 <br /> y SJ C T PHS-E VIR NMENTAL EALTH DIVISIC MASTEAFILE RE' 7 INFORMATION FORM{EH 00 691a.ri..a areal} <br /> 1) <br /> Eft P 9 IE. C g F ility New EH Program/New FaF D t <br /> SHADED SECTIONS FOR LOCAL USE ONLY17�l RECORD ID # <br /> J�'j <br /> FACILITY ID # �� ( '✓ r ✓I n <br /> Please Mark the Appropriate Description and Speolty size andlor Number o}Units where Applicable: <br /> _DAIRY PROGRAM {2000} �3 � � <br /> Greae A Dairy Grade B DNry Milk Dbpempr Number of Contdnen In Multi-Heed unit <br /> FrRetaH <br /> FOOD PROGRAM {1600} <br /> 1 sane.,c.p.Nty 1 saint.Fomea Produce Stand Ice Plant <br /> rantNumber of VMta <br /> 1 Orr sm..,n omr I with Food PrePmntlon Vendin MachinesssarI amunre PomngeI whM1 Ment Mnrket udy1 with Food P.. nrntlmr I OrY OoM ody <br /> MarksI Make Vehicle Type ; Cdor ; Re,l.hetlon R U..m.:r <br /> ehicle I Vehiele Type I color i Regi.tmdon#Make <br /> oFood Unit 1 <br /> Temporary Food Facility Special Event <br /> Date,of OPe..tlon from to Date.of Operation from t° <br /> _HAZARDOUS WASTE PROGRAM {2200) <br /> 1 Tone gso...led pares, <br /> Hazardous Waste Generator <br /> I <br /> Tiered Permit Facility <br /> 1 Cetapodcelly ethgzad 1C eogoH.Affy Exam <br /> t PermR by Pula <br /> _ HOUSING PROGRAM (2400) EMPLOYEE HOUSING {2700} <br /> I Ntenber of Unit. Number of EmplaYeee Dairy Employee Hguein0 <br /> F <br /> tel/Motel <br /> Approximate Daws Of 000uPaney <br /> l or Exempt Institution to <br /> _LIO.UID WASTE PROGRAM {4200) <br /> I Registration# 1 uean,e R I Capacity I Vahid.# <br /> PumDer Vehicle <br /> Number of units <br /> IF—IF-pumper Yard Package Tr atment Plant I Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500) <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> I <br /> 2-10.°....tors 11 -60,.....tore >60,ammo. <br /> Common Storage FacilityI <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool I Spa Out of Service Pool/S s Natural Bathin Area <br /> Number of Pods/Spas.t Facility PodIS,ID# <br /> SITE MITIGATION PROGRAM {2900) <br /> ElWkonmental Assessment USTICAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site i CA EPA-RWDCB 1 CN EPA-DTSC I US-EPA <br /> I NPL 611. 1 want OuNity bite I other <br /> SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station A /Canner Waste Sita <br /> Number of UNu <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Waste Tire Facility Process/Recycle Facilit Dum stere >20 cu yd Number of Unit. <br /> VECTOR CONTROL PROGRAM {4000} <br /> Poultry Farm Meeimum fluent.,of Birds Kennel <br /> Emergency Notlfi—flon for his FACILITY nndlor PROGRAM on, Night <br /> CONTACT PERSON: ( I ( I <br /> Designated Employee# Program Bement it Cu.....t Status Number of Vnits <br /> spare y ma eriawe y Data .count ng .. ew nit Clark W.I. Unit to L6ete <br />