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15J CC !'fY PHS ENVIRONMENTAL HEALTH DNI MASTERFILE D INFORMATION FORM{B1 00 6900wood 6/94)} <br /> r` New EH Program/Existing Facility New EH P►ocram/New Facility Dote S <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> CIL <br /> Please Mark the Appropriate Description and Specify Size andfor NUFnber of Unite where grpRoable: <br /> DAIRY PROGRAM .{2000} <br /> Grade A Dairy Grade B Dairy <br /> Milk Dispemar Number of Containers In Multi-Beed Unit <br /> FOOD PROGRAM {1600} <br /> 1 Seating Capacity I Square Footage Produce Stand Ice Plant <br /> Restaurant �71 <br /> I Dry Storage only I with Food Preparation VendingMachines Number of writs <br /> Commissar <br /> I Square Footage I with Meet Market only I with Food Preparation I Dry Goods orgy <br /> Retail Ma'ket <br /> 1 1 Uoense I <br /> I Make I Vellcle Type Cofor 1 Registration I <br /> Food Vehicle 1 1 <br /> I. <br /> Vehicle Type I Color I Registration• Ucenss <br /> —71 <br /> I Maka 1 1 <br /> Mobile Food Unit <br /> Temporary Food Facility Special Event <br /> Dates of Operation <br /> from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tons genernted per year <br /> Hazardous Waste Generator I 1 <br /> Categorically <br /> I Categorically authorized <br /> Exempt 1 Permit by Rule <br /> Tiered Permit Facility1 <br /> HOUSINp PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Units Number of Employees Defry Employee Housing <br /> Hotel/Motel <br /> Approximate Dates of Occupancy . <br /> to <br /> Jail or Exempt Institution <br /> LIQUID WASTE PROGRAM {4200} I <br /> I Registration A 1 Ucense s I Capacity 1 Vehicle! <br /> Pumper Vehicle I <br /> � Number of Units <br /> Pumper Yard Packa a Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primar Care Acute Care Skilled Nursing <br /> ll <br /> Small Generator <br /> Transfer Station Limited Hauler PizCliniic <br /> 171-60 generators - j > <br /> 2-10 generators <br /> 1 <br /> Common Storage Facility �p <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool S a Out of S S vi <br /> Pool/Spa IDS ..- <br /> Number of Pools/Spas at Facility SITE MMGAnON PROGRAM {2900} �Nv\ <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline— <br /> I Cal EPA-RWQCB I Cal EPA-OTSC I US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Site 1 Water Quality Site I Other <br /> SOLID WASTE PROGRAM {4400) <br /> Landfill- Transfer Station A /Canner Waste Site y" <br /> Number of Unit <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Waste Tire Facilit Process/Recycle Facility <br /> Dum eters >20 cu d Number of urge <br /> VECTOR CONTROL PROGRAM {4000} (o D <br /> Maximum Number of Birds C ,Kennel <br /> Poultry Farm <br /> Emergency Notification for this FACILITY and/or PROGRAM C Day Night <br /> .6:_ <br /> ee_;. 44i <br /> ' CONTACT PERSON: �9�y�� do 5114,19110Ai CCx � ) A <br /> Designated Employee <br /> +� <br /> prom <br /> Be1tiMH+1 .> .: Current StatusN ay"of Unita _B/A <br /> ._ <br /> f..;. Q. <br /> } : �. <br /> Clerk <br /> Receive y :ets aura to IIQ p <br /> . Ce t. <br />