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CIYnerm Ont 1. Co v. IDipp w. L4nN �cC. T aC <br /> SJ COUNTY PFIS - ENVIRONMENTAL HEALTH DIV'' MASTERFtLF I' -ID INFORMATION FORM {EH 00 58(tt.+ieed 61941) <br /> New EH ProgrumlExisting Facility New EH ProgramlNew Facility . <br /> L Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILTRECORD ID 4 5D'7/5l <br /> Please Mark the Appropriate Description and Specify Size andfor Number of Units where applicable: <br /> DAIRY PROGRAM {2000} <br /> ,T. - A Dnlry CreAw 6 DnirV Milk Dinpnn.ar Nara,bar Elf Container. Vn Meda-Head Unit <br /> FOOD PROGRAM {1600} <br /> I Sanunp cnonary I Squnrw F9nrwge <br /> Restaurant <br /> Produce Stand Ice Plont <br /> C <br /> � nry Srnrnq.rl nlY I witl,Fend Pr9 pnrntinn onlntissar 7FVending Machines Ntnnher n(u it. <br /> t Sr lw Fnninge I will)M.nl Mnrk91 i.9rY 1 wirh Fnpd PrwpnrwUpn I <br /> ReTafl Mafket {try Good.unly <br /> t i <br /> Faod Vehicle I 'mo w 9 Velticle 7vnw S Color I Regiatrnnpn s ' Uaana• a <br /> L <br /> V.hiclw Type 1 f <br /> Mobile Faod Unit , Mnkw l cnlnr Nef <br /> I I r gi.tanann O � Ucensw I <br /> I <br /> i <br /> Temporary Food Facility Special Event I <br /> Onoa. of Operncion Rn'n m Dnna of OPerntion Ram to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> I per year �C�t7 _ <br /> Hazardous Waste Generator Tam qep rated <br /> 1 I l r <br /> Tiered Permit Facilitv ".tho,iz.d I G.teUtirlcvttrl Exe.rtpt Permi;by Rtd. <br /> HOUSING PROGRAM! {2400} EMPLOYEE HOUSING {2700} <br /> I <br /> HotellMotel Nmnbwr of Unite Number of Enpipyeae Dmry E-pfoyea Hou.mq li <br /> Ap proxim nae Hata.Elf Oecupnncy <br /> Jail or Exempt Institution <br /> to <br /> LIQUID WASTE PROGRAM {4200} <br /> I R.com-no., 7 I t1cene l 1 CnVn ity I V.hmi. # <br /> Purn er Vehicle <br /> 1 <br /> Pumper Yard _-Package Treatment Plant Chemical Toilets i Number of unix <br /> MEDICAL WASTE PROGRAM {4500 <br /> Primary Care Acute Care Skilled Nursin Large Generator <br /> + Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 2 10 genera tc r. I 11 "68 .—ritnr. 1 <br /> Common Storage Facility I r q I >so U--[­ <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool S12a Out of Service Pool/Spa Natural Bathing Area <br /> Number of P001.1st'— .,Facility Poolfspn In C <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment USTiCAP Local Haz Waste Haz Mat Pipeline_ <br /> Other Lead Agency Site 1 Cel EPA RWIILB I cal EPA-arse t US-FPA <br /> I <br /> 1 NPL Sit. I W.1de Otrality Site I Other <br /> SoUD WASTE PROGRAM {4400} <br /> i <br /> Landfill Transfer Station An/Cannery Waste Siteir <br /> CIA Landfill Site Sludge/Ash Site Numbs of V ite <br /> Compost Facility Refuse Vehicles <br /> Waste Tire Facility Process/Recycle Facility Dumnsters >20 cu yd N,—b.r p(Wws <br /> VECTOR CONTROL PROGRAM {4000} <br /> P <br /> Mnxnnnrn Number nr gird. I1 nuilry <br /> Farm _FK. Ip <br /> Bnorg9ncy Nnnfirnnnr, !or Thin FACru TY.ndlor PROGRAM Ilm+ Night <br /> CONTACT PERSON: r [ } <br /> D91iq!mled Ernoloye. .T Program Element A .y X Currant Sratue Number of Unita FPA JD r <br /> c '�' c-I G <br /> 9c9rved by Date Ra gwed by Ditto Aceuun[mg 0I1c9 Dew Ikt Glerk wtrt + ant to aw <br />