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SJTY PHS - ENVIRONMENTAL HEALTH DIVI!" / MASTER LE RF-ARD INFORMATION FORM{EH 00 59(R—i—d 6/9411 <br /> **I New EH ProgramiExiating Facility New EH ProgranvNew Facility 11w Date <br /> SHADED SECTIONS FOR LOCAL USE LONLY <br /> FACILITY ID # Oo q (f q 5 RECORD ID -)'70 5Zo J <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} <br /> Gf.d. A Dairy ..red.B Dairy Milk Disp.nlwr Number of Contninwn in Multi-Head Urui <br /> l �I I <br /> FOOD PROGRAM {1600} <br /> I S.nbno Cnn—iry I Square Foot.a. Produce Stand Ice Plant 1 <br /> Restaurant I <br /> I Ory Storaga nniy I wnh Food PrePmnnon Number of Unit. <br /> Vending Machines <br /> I Snunrn Fmnnoa I with Mwm MerNwt ufav t widr Food Prwpnredon I Dry Good. only II <br /> Retail Market JI <br /> I MMfw I V.Ncle Type I Color I Rwgi•bnaon I Uoeme/ <br /> Food Vehicle <br /> Mnk. 1 V.liclw TVpw I Color i ReP.tretion f i Ucen.e ) <br /> Mobile Food Unit <br /> Temporary Food Facility Special Event <br /> i <br /> Dares of Operation from to Date!of Operation from to <br /> `r HAZARDOUS WASTE PROGRAM {2200} <br /> I Ton! q.—m.d per year <br /> Hazardous Waste Generator <br /> Catagoricaily authorized Catagoncnlly En.not I P—it by Rtde <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Unds Number of 6nploye.. O-,y Employee Houlinq <br /> Hotel/Motel <br /> App—n—te Date!of Occupancy j <br /> Jail or Exempt Institution tO <br /> LIQUID WASTE PROGRAM {4200} <br /> I R.QIlirntlon X I Ucen.w S I C.0-ay I Vehicle 0 <br /> Pumper Vehicle I I <br /> Numbs of Unib <br /> Pumper Yard Packa a Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> i <br /> Primary Care Acute Care Skilled Nursing Lar a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> -10 g.neretor. l 11 -60 generetnr. I >60 genereton <br /> Common Storage Facility l <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> I <br /> Pool I Spa Out of Service Pool/Spa thing Area <br /> Number of Pools/Spa! at Facility Poolfspa I0,1 II <br /> SITE MmGAnoN PROGRAM {2900} <br /> Environmental Assessment USTiCAP Local Haz Waste Haz Mat Pipeline <br /> I Cal EPA-RW OCB I Cal EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> I NPL Site I Water Ouaiity Site I Other <br /> SCUD WASTE PROGRAM {4400} <br /> II <br /> Landfill Transfer Station Ag/Cannery Ag/CanneryWaste Site <br /> � Number of Unit. <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Number of Units <br /> Waste Tire Facility Process/Recycle Facility Dumosters >20 cu yd <br /> VECTOR CONTROL PROGRAM {4000} <br /> M—rn.—Nf—b.,or Bird! Kennel <br /> I Poultry Farm 'I <br /> 6 n.r._y Nnnficntion for tbie FACIUTV and/or PROGRAM Day Mum <br /> CONTACT PERSON: ) <br /> Dalignnt.d 6nploVae A I Proqrnm r7emen[4 .-�'"7 � Current stnhu I Number of Units FPA 10! <br /> R.--n toy D.t. R.ylew.d by Date cpounnnq Olt— Date rot clerk ate I n[TEaTf ate <br /> a: <br />