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I'Y a- U VU it< <br /> SJ COUNTY H -ENVIRONMENTAL HEALTH D )N MASTEAFIL aORD INFORMATION FORM{EH 00 690'r—ir ul 6/e41} <br /> IFNew EH Frogrem/Existing Facility r New EH ProgramlNew Fecility q Data <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY ID # RECORD ID # <br /> Planes Mark the Appropriate Description and Specify Sze and/or Number of Units where epplioeble: <br /> DAIRY PROGRAM {2000} <br /> Crede A Dairy Grade 6 Dalry Milk Disperser Number of Castanet.In Muld-Need Unit <br /> FOOD PROGRAM {1600} <br /> Restaurant I senting Cepachy I Serum.Fort.,.1 11 produce Stand Ica Plant <br /> Commissary <br /> i Dry am....only 1 with Food Preparation Vendin Machines Number of Units <br /> 1 111ReSquare Foot eye 1 with Ment Market only 1 with Food Preparation I dry Goods truly <br /> tail Market <br /> I Make I V.Nale Type I Color I Registration# I U.....Jr <br /> Food Vehicle I 1 1 1 t <br /> I <br /> Mobile Food Unit Make I Vehicle Type I Color I Rrorlhu ado, # I Uoem. t <br /> 1 I I 1 1 <br /> Temporary Food Facility Special Event <br /> Det..of ovemden from to Dm..of Cranston from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> Hazardous Waste Generator 1 Tons generated per year <br /> Tiered Permit Facility <br /> j C.tagodcally .rrthmlzed Categorically Exempt Penult by Rule "7 <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> Hotel Motel 1 Number of Unto Nsnb ,of Employe.. Entry Employe.Housing <br /> Appmxlmat. aero.or Googpeney <br /> Jail or Exempt Institution to <br /> _ LIQUID WASTE PROGRAM {4200} <br /> Pum er Vehicle I Regletr.tkm A 1 U.....If I Capacity V.locle It <br /> Number of Unit. <br /> pumper Yard Package Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> L <br /> mrCareAcute Care Skilled Nursin Lar a Generator <br /> all Generator Transfer Station Limited Hauler Veterinary Clinic <br /> mmon Store a Facility { z-to generator. i 11 -so generate,. >so g.o.rsm.. <br /> RECREATIONAL HEALTH PROGRAM {3800} <br /> Pool Spa Out of Service Pool/Spa -___Natural BathingArea <br /> Numbs,of Poole/Sp rs at Facility Pool/Spa ID# <br /> SrTE MFnGATION PROGRAM {2900} <br /> Environmental Assessment USTICAP Local Haz Waste Haz Mat Pi eline <br /> 1 Cal EPA-RWGCB 1 Cal EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Sim I Water Qoadty Site I Other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station A /Cannery Waste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of Unite <br /> Waste Tire Facilitv, Process/Recycle Facility <br /> Dum eters >70 on yd Numbs,of Units, <br /> VECTOR CONTROL PROGRAM {4000} <br /> Meximr.n Number of Birds Kennel <br /> Poultry Farm <br /> Fmo,ncy Nodficatlon for this FACILITY end/on PROGRAM /� /J„ Doy Nights <br /> CONTACT PERSON: 'V11 . I 1 <br /> D..igdeted Employee p Prograrn Element Current St."" Number el Unlet ,�Phl ID <br /> p—Y ✓ G t <br /> eomye y ata y to crounmlg a tus,Clqrk trust Stan Data <br />