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y C�Ir ec �.��x` �?t�n `�rel.i�ti`1— r'J i—L..-Y ,'�C i��t�1 <br /> SJ COUNTY PHS - ENVIRONMENTAL HEALTH DlyaW MASTERFIL VRD INFORMATION FORM{EH 00 59(Revieed 6/941} <br /> Date <br /> New EH PmgramlExisting Facility New EH ProgramlNew Facility `,`� <br /> �_'— <br /> SI-IACED SECTIONS FOR LOCAL USE—O7NL Y -}� <br /> FACILITY ID # �v < (n J RECORD ID # 67 <br /> -70-72 <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 8 Dairy Milk Dispemer Number of Containers in MWb-Rend Unit <br /> FOOD PROGRAM 11 600} <br /> I Seatino Cao-city I Square FootageProduce Stand Ice Plant <br /> Restaurant <br /> I Dry storegw only I will,Food Prep-anon --7F—V.ndinq Machines Number of Unit+ <br /> Commissar <br /> I Sm.—Footage I will,Ment Market nnly I with Fnod Prwpwradon I Dry Goode only <br /> Retail Market <br /> 1I Re •Iradon ! I e/ <br /> I Mahe I vehicle Type Color Uoene <br /> I � 1 <br /> Food Vehicle I <br /> i <br /> f I Re •{radon T 1 Uoeme 0 <br /> =One-11011 Mnke VxlJcle Typw Color T IilitySpecial Event <br /> from to Dates of Operation from to <br /> WASTE PROGRAM {2200} <br /> I Tons generated per year <br /> Hazardous Waste Generator <br /> i Categorically authorized Cetegodcrily Exempt I Permit by Ride <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Urdu Number of Ernployews Dairy Employee Housing <br /> Hotel/Motel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> Registration A <br /> I License s I Capacity I Vehicle 0 <br /> I I f i <br /> Pumper Vehicle I <br /> I Number of Unit. <br /> I <br /> Pum er Yard Package Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {45500} <br /> i <br /> Primary Care Acute Care Skilled Nursin Large Generator <br /> Shall Generator Transfer Station Limited Hauler Veterinary Clinic <br /> I1 11 -60 generators l <br /> 1 2-10 generators >60 generator.l 1 <br /> Common Storage Facility <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool I Spa- Out of Service Pool/S a Natural Bathing Area <br /> Number of Pools/Sp" at Facility poollspe ID A <br /> SITE MMGAT1ON PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pi aline <br /> I Cel EPA-RW QC8 1 Cal EPA-DTSC i US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Site I water Qudity Site 1 Other <br /> SOLID WASTE PROGRAM {4400} <br /> I <br /> I <br /> Landfill Transfer Station A /Canner Waste Site <br /> Nimber of Univ <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Number of Units <br /> Waste Tire Facility. Process/Recycle Facility Dum stars >20 cu d <br /> VECTOR CONTROL PROGRAM {4000} <br /> Maxim,—Number nt Rird. Kennel <br /> POUltry Farm <br /> Night <br /> Emergency Notific-ntion for this FACILITY and/or PROGRAM <br /> Dov <br /> CONTACT PERSON: f <br /> Pro rnm Bement x Current Status Number of Units EP Of 7 2 <br /> Designated EnploYee p 9 �J ZJ _y t, 3 I <br /> (' (/ 1 rvt C ark <br /> at. ret to ate <br /> Reserved by Data Reviewed by ate caoungnq D hce ata <br />