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Attachment E: Local Mass Clinic Facility Worksheet <br />Local Strategic National Stoclqrile/$Iass Clinic Feciliry* Worksheet <br />CountyName Public Hedth Resion #: <br />Facilitv Code:Facility Name: <br />Location Cross Street:Facility Address <br />Facility Onmer:Facility Orc,'ner Phone: <br />Altemate Point of Contact <br />Name.'Title: <br />Day Phone: <br />Evening Phone: <br />?hone,r <br />email: <br />Primary Foint of Cantact <br />Narne,'Title: <br />Day Phone: <br />Evening Phone: <br />email address: <br />Phone / <br />Facility capacity:Sq. ft":Number of Parking Stalls- <br />tv <br />68-lclinic slea <br />use <br />L <br />soluce: <br />itents -_--_"- --i--_- <br />temp lnn <br />n <br />Itr <br />clinic <br />iinii <br />other <br />eree <br /># ofexternal lines: <br />ll Ser.'er or I on-site seqrage system <br />soluce <br />access <br />Alt available: <br />Helicopter landing pad: <br />athletic fields <br />Plan customized to frt facility, follo*'ing attachrnentsn <br />listsrte <br />!erPleleg <br />Local H ealth Juris diction:Las' Enforcement Ag enry: <br />Fire SenicesEmergency Management: <br />Chief Elected Officials Facility O*.rrer: <br />With: <br />56