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Attachment E: Local Mass Clinic Facility Worksheet <br />+ Local Strategic National Stockpile/Mass Clinic Facility Worksheet <br />County Name: -Pu.blic H ealth R egion #: i <br />Facility Code: ) <br />F acilily Address: : J Location Cross Street: <br />Facility Owner: : j Facility Owner Phone: <br />Primary Point of Contact Alternate Point of Contact <br />Nameffitle: Namcfulle: -----------------------------------• <br />Day ~one: ___________ -+-_______ D_a .... y_P_h_on_e_: ___________ -11 <br />Evnung Phone: Evening Phone: D<;c_!! P_:h_~e l ~~:' ----------------:r==1"Cc:ll--P-h-on_e_/-=o=-;ig-a-; -------------ti <br />email address: email: i <br />F.i.clllly capacity· I Sq. ft.: Number of Puking Sia.Us : <br />'DE! J. ~~-u_s~ -~.,n~Mt ~p!!ce . ... .. .. .. t1' g.. FL_!._ <br />0 <br />nacmd'.,-:.&g.Jd:l <br />0 <br />'.~~~ fad!!:~ .JJ!!:'!'!'d loa~_g ~.ea <br />' Elcctrlcit}• (adcqua.1courJets n dtnic .trea) U ' w ex • SacknpJIOS'~eT-;~;rce -I ID Te.iephonea~m:ti, # ofextemiii.Jmes: - <br />Q ! <br />0 <br />A dcqua:1eroad.access l D (add,o!her if;!,!!s qji~,.~~J. . 0 · Water source: 0 (add at/rtn" items o/tnllt1"11St het:tt) <br />Cl . :'fo~_~tr?O~ ~of ~s: L'iJ .Jp~1_-o!if:, ite!!.!f iJi~l'.?t,_i!S!.!.~.l " Ii • • .. <br />j D Adcquiue HVAC capacity 10 m_aint:un n~" tmip in <br />· clinic area (as llttdmg.stqrage. irulddine.s. 68-77<'!1) i O Sewer or O on-sit e sewage syst~ <br />Q f Bd:kopter landing pad :'[j1 ~n-site /[] n~axby <br />athletic fiellds <br />D Plan cuitomizcd lo fit faality, followin.g attachmcrus <br />..- <br />-- <br />· 0 l Aii: trauliPortation ;n,ailible: <br />--' complcud 1 [i]f Location mat> 0 site plan 0 clinic plan O needed eqmp list <br />Facility "Pl-in Coordina~ed With: <br />Local Heahh Jurisdiction: ., 1· La~v E~orc~ent Agency: I <br />~-E_m_f%S:'1cyM~~=-~.:=-=======================c·-·· ,. ·-·-··· ~ire_ Scm~~-s:_ I __________ , <br />Chief Elected Officials: ! F adllty Q~,ter: <br />a <br />56