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HS-ENVIRONMENTAL HEALTH D <br /> NISI MASTQiFtLE R D 11tIFORMATION FQR�I{ OQ 681Redsad <br /> s � ' � <br /> New EH Program/Existing Feoility GlA� New EH Program/New Facility Date '" <br /> -SHADED SECTIONS FOR LOCAL USE (ONLY <br />µ.:,. <br /> ORO. <br /> •:#171 <br /> .. <br />�z <br /> C <br /> r <br /> ::PA I 'Y` <br /> Pleoop Mark the APP[O riet®Depar tiosf attd S eoify Size and/ar umber o Units whpfe aPp1la <br /> " <br /> DAIRY PROGRAM {2000} <br /> 1: <br /> grade A Dairy grade B Decry Milk Qispenset ' Number of ConWpare In Molt}Haag 4nll <br /> xom .a <br /> FOOD PROGRAM {1500} <br /> 1 Seating Cepeolty i Square Footage P odw a Stan Oe an <br /> Restaurant <br /> 1 Dry Storage only i with Food Preparation Number of Unita <br /> `Commissar Va di Machines <br />*° 1 Square Footage i with Meet Market only i with Food properatioq 1 Pry goods orgy <br /> Retail Market <br /> 1 Make I Vabiole Type I Color I Rsglatratlon* ! tomes S <br />' Food Vehicle 1 1 <br /> 1 Mak. : I voole Type .. I color ! Regispadon s I uoerat <br /> Mobile Food UnitONE <br /> I i ' <br /> d; <br /> `; Temporary Food Facility Special Event l•' f t"'� ° <br /> t.' <br /> pates of Operetlon from to Detect of Operation iron!'-' <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> Hazardous Weote Generator i Tons generated per year a. ,PUBO IC ',. ...'� <br /> Tiered Permit <br /> Facility Cetegodoegy authorized I.CetggorloaNy ExemptElfTi �+s'� "2'H DIViSIO <br /> HOUSING PROGRAM {2400} <br /> EMPLOYER HOUSING {2700} <br /> h. I Number of Urgb Number of Fmployeae Prg7"ploys,llousino # � <br /> e oe <br /> Approximate Dotaa of Ooomponoy <br /> Jail of Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} .. t <br /> I Registration S 1 tlosnse rr,;, :, i,Gapargty „°;� i vowels,d <br /> t <br /> Pumper Vehicle <br /> Pumper Yard Packs a Treatment dant [Chemical ToNete ' <br /> .Number of 11ndp <br /> r MEDICAL WASTE PROGRAM {4500} • r ° <br /> d - • <br /> PrimaryCare Acute Care " Skilled Nursing Large Ge a stor <br /> Small Generator Transfer Station .`' Limited Halder Veterinary Clinic <br /> • <br /> Common <br /> Storage Facility <br /> 2.to generators ! t t c eo Qen.rawa I6A�ent!reton <br /> " 4 -RECREATiONAL HEALTH PROGRAM {3500} ,.. . ., <br /> 'tic g a Out a Sery ce oo S a at i A e <br /> of h'.1 <br /> . .. / .....:......................:............sw,;�::::::::::.•.v:w::.�:::..�.:::r.4h{ti •yiiii:�:::fr::jyi':i::i:�'^�i:Y•?':IX:•iivx:§:-0r .< <br /> Numbat o dS as at FaolU ,, .::�4:•:::Q,�..�:..,;..{._:•:i•;•:;•:•::::.�::::::.�::::::::::•:.,:•:::.�::::::::::::{:•.:•::::::::.�:::: :.<a•o-i:a;•:•iso}:aJo-:•?r;::::•}}:•:•:•::.:::::::;;..:. <br /> SITE MITIGATION PROGRAM {2500} •, k .'s, <br /> oviionmentai Assessment UST CAP Loca Haz Waste az Mat Pi eline a <br /> r , I Gad FFR•ftwace .` 1 Cal EPA.PT$c <br /> 'Other Lead Agency Site <br /> .acl'aR'y'..• "`1 NPS Site 1 Water quality Site ,i other <br /> i'94 :- <br /> SOLID WASTE PROGRAM {4400} <br /> :i>''F.::+•i::>}:i:•:vi:J:{::;`.`}:::•:::::{{:;:;.:}.$i':::{{.:�:v::ilii}i:{:>Tii>i:•:�}:4>:.?i::+:•%ii, <br /> •` <br /> '•i:0}r:' <br /> ce at Site <br /> ndfill Transfer Station }:• �• '• •• <br /> CIA Landfill Site '` Sludge/Ash Site " oat Fac ty R' Refuse Vehiclestytnnber of sada <br /> r.. Numbero Urlb <br /> k: f -=s,x <br /> Waste Tire Facility Process/Roc Faciiit <br /> : ss:.; Dum sters >20 cu d ,...� <br /> VECTOR CONTROL PROGRAM ,{4000} r •' Q.F'� ` <br /> `pOUifry Farm Maximum Number of <br /> Kennel' <br /> Emerpe�Y Notification for this FACILITY !/at pRo¢flA1� <br /> �.D <br /> ,CONTACT PERSON•. ,QA�¢oN' 1QUB (`20`j <br /> d i 1 i'alh"6. Sake O. <br /> h�r et r' <br /> IIdt9...Cxtt 'R:�`>i8•`':::[: ^� :::: E� ;i� <br /> s:-tkid u <br /> .... ......•.... ....... ,,................ .. .. ... ..,•.. ...,.......• .......'^.R..}......�..... :•i5:?............,....�i•�ri>'::'.}5>r.;•:£6si:�i�ir :::.:. :..{.....r :�.�'Y <br /> <;::i;•:{•:{ii:Si:: 91A.c:;`F:i%-I::: eM AW :: ,;i•:.:::•:. <br /> .:.:...................... <br /> { ::::::•;,{;.;i::{:::: ate:;>{:;:+:: :. o a n is :::::.: ta::i:i:. t.: :•. .:.:•....::.:.: .t:_::>:..;:},::.i c: :.}.:::.. <br /> ..::::... ....................f........:....:,:::::.•::::.::moi}i}>io-?. ....... ............... {.:••::}.}::•::: •.. .:..,.:.. ..,.....,...>..:...............:: <br /> Eii2''•icX. <br /> aic`.'•i;i;i;i't;'!.;::;:!iii;?i;>;i;:;c3'S;> <br /> ::.�:::{,•iii:.:•::.:{.?�:::}>::. :{y:;:} <br />' d <br />