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�b.l CrUP Y PHS-ENVIRONMENTAL HEALTH DNISI MASTERFILE R&INFORMATION FORM(EH 00 699(Revised 6/941} <br /> New EH Program/Existing Facility I LLA)d New EH Program/New Facility Date / Sr <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> IAYLSE CI <br /> OR <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 B Dairy Milk Dispenser Number of Containers in Multi-Heed Unit <br /> FOOD PROGRAM {1 6001 <br /> I Seating Capacity I Square Footage <br /> Restaurant Produce Stand Ice Plant <br /> I <br /> Commissar Vendin Machines <br /> Dry Storage only I with Food Preparation Number of Units <br /> 1 Square Footage I with Meat Market only I with Food Preparation I Dry Goods only <br /> Retail Market <br /> Make 1 Vehicle Type 1 Color 1 Registration# I Ucense a - <br /> Food Vehicle 1 1 1 1 1 <br /> Make 1 Vehicle Type I Color I Registration X 1 Ucense r< <br /> Mobile Food Unit I 1 1 I 1 <br /> E <br /> y Food Facility Special Eventration from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {.2200} <br /> Tons generated per year PU <br /> Hazardous Waste Generator ° p v BL{C AL <br /> Categorically authorized Categorically Exempt NTr461tl�R�li DIVISi <br /> TEP li'l <br /> iered Permit Facilit ORi <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Units Number of Employees Dairy Employee Housing <br /> FH.telel <br /> Approximate Dates of Occupancy <br /> mpt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> Pumper Vehicle I Registration x 1 Uoense x I Capacity 1 vehicle a <br /> rPumper Yard Package Treatment Plan Chemical Toilets 1 Number of Units <br /> MEDICAL WASTE PROGRAM {4500} r <br /> Primary Care Acute Care Skilled Nursina Lar a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility 2-10 generators t I-60 generators >60 generators <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pol <br /> Spa Out of Service Pool S Natural Bathin Area <br /> Pool ' Eo- ::'?...`ii:"•:�i..cf>' ?E'•'•.2t' i•a:?::;;;•>:•}?::.a:}:-:.:: ::"• <br /> 0 :•aa:•a:•a:•:fa:;;.;:;.ai :•; <br /> S as at Facility _.p ,.........:.:..:..................:.:.....::: :•:::::::.,::::::::,:::::::. >:•:.:>:>:::.::•?:•aaa:-a.;;-a:r>a:::o:<•::.;•:;:•ao-:;•}::;::•:?a::•r:a:<•:}:>:.:.:as. <br /> [Nu.0l.r oEP..l s/ p ty <br /> ••a:?2::(:�i::�R11 <br /> :;:S;:;:::'r::::r>:;;:r:€n:�?:�21:;;o::a>:<•?rrnr:i;ax<;•>:•>}>:as:�>:�>:;i;•a::�»>:>:•:�a:;•�;;•}?::�;o:•:::<w.ar:•>:•a:.::•r:•:<;.:a:>:•?}:o-:•::;;;•} <br /> SrrE MMGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site I Cel EPA-RWQCB I Cel EPA-DTSC I US-EPA <br /> 1 NPL Site I Water Quality Site 1 Other <br /> J SOLID WASTE PROGRAM {4400} <br /> :::>.•?i2�ii�>'>'S3:'t8>?i:'•Sr':i�:%>€>;i}:;a:;;:;.'+::.i::::::: 5;::;�::;:3::6:::i%•;i;:::::%::c•:'•5>'::,i:�%:r <br /> ��tiiEiiFi�i�iiiii: 2iii3i>ii �i�<iiiii;':i;%%2`•::i3ii;:•::.:�::::.,.•:::.,:+ <br /> Landfill Transfer Station A Canner Waste Site ��i?#v�i#i`'�>�`�:<<?�i:.:.:•�. :::::,•:•::.:•::::::•:::...:::....:::::..:::•:::.;.:..;:.;...:.:-:::.,.:�:_ <br /> CIA Landfill Site Sludge/Ash Site CmRo.t Fac rty Relme VOIA*W Number of urns <br /> ';€: .gtii:,•ii: Numb <br /> Du <br /> or of Units <br /> ro eas Rec cle Facilit a;•>. ;•:+•z•}s>};a m tars >20 ou <br /> Waste Tire Facili P c / +aa `t>::.. . <br /> ... <br /> VECTOR CONTROL PROGRAM (4000) ,r`3�j. t 30 <br /> Maximum Number of Bltds <br /> Poultry Farm Khnnel <br /> Emergency Notification for this FACWTY and/or PROGRAM Day Night <br /> CONTACT PERSON: 442on1 f3 eU,84,`4 ( 21`j ) S-'IS-'Is (2l9 5�5-6y11� <br /> :r a <br /> w.. •• ., . <br /> 1s::• <br /> sa,�bM.rtatad;:Empl }lhti�.::;}->s•:::�;:::•�•s::<?�;a::• •"'fbrtiii�glNl�Wx•: irurrenf8tatus 'Number ot;Unite EPA 16#' y aa:: <br /> :.. ��. .....f:>. <br /> :. <br /> .... •:..:;a••:9'•:r.. tiY•, n�.::.n;:{::::.}?;:•..........:.:::f.�}::'a:;.ti,`.;�i?:•:}... •`:::{. <br /> irr::::%=: r :?::•:.t m c pta.: tgt .N ?<;. .•�},:ati+r:... .ta'. t <br /> Famm <br /> :::::..:::•aa::.::•a:}•::.�.:.. gla <br /> .n.n;....... .,+,:•a?aa:v:?.y.}v4:'i•:?:•:+:}ia'�i:•..:.. .::v,v...? ,:,x, F:•v,..>.+w, f.. r.y,• ,ti•Wi.. '.:Y' ./ L .6:i� €y;€>•::i <br />