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jSJ COUNTY PHS- ENVIRONMENTAL HEALTH C ON MASTERFh CORD INFORMATION FORM {EH 00 59(Revi.ed a/eaI} <br /> fNew EH Program/Existing Facility New EH Program/New Facility I �� Date z� <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY ID # U i RECORD ID # <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} <br /> Grade A Dairy Grade 6 Dairy Milk Dispenser Number of Containers in Multi-Heed Unit <br /> FOOD PROGRAM {1 6001 <br /> I Seating C.Pncity f sgmane Footage Produce Stand -IFIce Plant <br /> Restaurant <br /> I Dry Stnrnge only I with Food Preparation Number of Unite <br /> Conuniaaar Vending Machines <br /> I Square Footage <br /> I with Meet Morket only I with Food Preparation I Dry Goods only <br /> Retail Market <br /> 1 Make I Vehicle Type 1 Color 1 Registration 0 I Ucemse A <br /> Food Vehicle 1 1 1 1 1 <br /> I I I I I <br /> 1 Make I Vehicle Type I Color Registrntion A i Ucense A <br /> Mobile Food Unit I I 1 <br /> r I r I I <br /> Temporary Food Facility Special Event <br /> Date.of OPeradon from to Data,of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Torn gonernted par year <br /> Hazardous Waste Generator <br /> Gfll9 ggflCally authorized Categorically Fxemp[ Permit by Rule <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> -- I <br /> I Number of Unite Number of Employees Dairy Employee Housing <br /> Hotel/Motel <br /> Approximate Data.of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> I Ragls trntion A I Lice— t! 1 Capacity I Vehicle A <br /> Pumper Vehicle I I I <br /> I Ntenber of Unit,Pum er Yard Packa a Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Shall Generator Transfer Station Limited Hauler Veterinary Clinic <br /> I1 11 -60 enereton 1 >60 generators <br /> 1 2-10 generators 1 g I <br /> Common Storage Facility <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool I Spa Out of Service Fool/Spa Natural Bathing Area <br /> Number of Pools/Spas at Facility PoollSpa ID A <br /> SFFE MMGATION PROGRAM {2900} 117 -15-0 <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Cal EPA-RW OCS I Cnl EPA-DTSC �'' <br /> Il <br /> Other Lead Agency Site <br /> I NPL Site 1 Woter Ounfiry Site Q <br /> SOLID WASTE PROGRAM {4400} SEP <br /> Landfill Transfer Station Ag/Cannery Ag/CanneryWaste Site <br /> iV4Tfea'OLefitl <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse VgMit5tRt9Nivli:i'JTAi_HEALTH 01VISION <br /> Number of Units <br /> Waste Tire Facility Process/Recycle Facility <br /> Dum stars >20 cu yd <br /> VECTOR CONTROL PROGRAM {4000} <br /> Maximum Number of Birds Kennel <br /> Poultry Farm <br /> Energancy Notification for this FACIUTY and/or PROGRAM Day Night <br /> CONTACT PERSON: ( } ( } <br /> Designated Employee# Program ement Current Status Number of Unfits EPA ID 1 <br /> Received y ate Roviewe y etr ccounting 0 fico ate nut lar Data Unit to to <br /> ,4'X-- -rli �S �- Zf �� <br />