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SJ COUNTY PHS-ENVIRONMENTAL HEALTH C. N MASTERFII .ORD INFORMATION FORM{EH 00 59(Re.i..d alabl} <br /> N .Eff P 9 IEx' ting Facility New EH Program/New Fecildy Date <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> FACILITY <br /> 1D # RECORD ID # <br /> Please Mirk the Appropriate D....iptlo,and Specify Spur erldlir Number of Una.where applicable. <br /> DAIRY PROGRAM {2000} <br /> Crede A Dairy Gred.B Den, Milk Dlepamm Number of Containers in Mdtl Meal UNt <br /> FOOD PROGRAM {1600? <br /> I sardine capecl,Y 1 S,—,.Footyaa Produce Stand Ice Plant <br /> Restaurant <br /> 11 <br /> C v I Dr storage only1 th Food Prepared.. II <br /> V d" a Machines <br /> Numb.,or unit. <br /> I Sman.Footepa 1 with Mae,Mnrka,ody I with Food Prepamdon 1 Dry Goode oHY <br /> Retail Market <br /> I Make 1 WlYcle TYpa 1 Color i Reda,retlon I (lasma l <br /> Food Vehicle I I I <br /> I name I V.N.I.Type 1 Color 1 R.pleeea ro I Uaen../ <br /> Mobile Focd Unit 1 1 1 I <br /> Temporary Food Facility Special Event <br /> D.,..or opera <br /> nom to Data.of Op imor- from t• <br /> _ HAZARDOUS WASTE PROGRAM {2200} <br /> 1 T.n. onmd"Par Y. <br /> Hazardous Waste Generator a <br /> II Cetaaoricdl Exempt I Permit by 0.d• <br /> Cetyporlcdly eutnodaad 1 Y I <br /> Tiered Permit Facility <br /> _HOUSING PROGRAM (2400) - EMPLOYEE HOUSING {2700} <br /> I Nwnber o1 Unita Nrmber of findoyeae Odry Employes Houeinp <br /> Hotel/Motel <br /> Approximate Dater of oeour, <br /> my In <br /> Jail or Exempt Institution _ <br /> _ LIQUID WASTE PROGRAM {4200} <br /> 1 p I <br /> I U.ema I I e.P.hy 1 VeNeN I <br /> Pumper V h I <br /> xunber of unity <br /> Pumper <br /> Yard Pack: a Treatment Plant Chemical Toilets <br /> Small <br /> MEDICAL WASTE PROGRAM {4500} RECEIVED <br /> er Carea -Ntasin enerator <br /> Generato7777EAcufeCaZrea1 <br /> Limited Hauler etermary Clinic <br /> 2- 11 .60 1 O atom pamralou <br /> Common Storage Facility I I SAN JUAO IN'C.�1910T'Femn <br /> FFN�ber <br /> RECREATIONAL HEALTH PROGRAM {36001 ENVIRONMEM S a Out of ServiceFool/S ir <br /> of Pooi.lsppe at Feciliry Po.USpe ID I' <br /> _SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Hair Was .FiSz Mat D;--.;n <br /> I Cd EPA-0.WGC8 <br /> I Cd EFA-DTSC UBEPA <br /> Other Lead Agency Site 1 other <br /> 1 NPL Sits 1 We,o Dwilry 61b <br /> _SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station A /Canner Waste Site <br /> N r of Unity <br /> CIA Landfill Site SludgelAsh Site mpost Feclity Refuse are I <br /> I N of Unit <br /> Waste Tire Facility Process/Recycle FacilitJMJy <br /> tars O c <br /> _VECTOR CONTROL PROGRAM {4000} <br /> Maximum Number or Bird. Kennel <br /> Poultry Farm <br /> o+i-v- p oar Mant <br /> Fmeraency N.dnceaxn ror tma o `)Dr�t�V I _ <br /> CONTACT PERSON: V I !V O O V/ <br /> FDeeg—tod Employee A Pr.N�wn Dement A Currant stn,ua Number or Unity FDA ID Ir ,anunate ate nt to cw 7- 3 -1? <br />