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SJ COUNTY PHS - ENVIRONMENTAL HEALTH DMS MASTERFILE P ID INFORMATION FORM {EH 00 591Revi.ed 6194)} <br />rNew EH Program/Existing Facility F New EH Program/New Facility Date <br />SHADED SECT/ONS FOR LOCAL USE ONLY�f G� I �_•'-1 ?t 1 <br />FACILITY ID # 601`1 ` RECORD ID #07�b -7 <br />Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br />DAIRY PROGRAM {2000} <br />Grade A Dairy Gradfl B Dairy Milk Dispen.n, Number of Containers In Multi -Heed 'Unit <br />Fnnn PRnGRAM I16001 <br />Restaurant <br />I Seating Capacity <br />I <br />1 Square FOntegfl <br />I <br />Lar a Generator <br />Produce Stand <br />Ice Plant <br />Limited Hauler <br />Veterinary Clinic <br />I> 60 generators <br />Common Storage Facility 1 2- 10 generator. I 1 1 - 60 generators I <br />eeeive <br />y ate <br />Reviewedy <br />ate <br />I Dry Storngfl only <br />( with Fond Prnparation <br />Vendinq Machines <br />Numbar of Units <br />COf1111115$Ar <br />I Squure Footage <br />1 with Ment Market only <br />1 with Food Propmatlon <br />I Dry Good. only <br />Retail Market <br />I Make <br />I Vehicle Type <br />I Color <br />I Registration A <br />I <br />I License A <br />1 <br />Food Vehicle <br />I <br />t <br />I <br />I <br />I <br />I <br />I <br />1 <br />I Make <br />; Vehicle Type <br />i Color <br />; Registration A <br />i Ucen.e A <br />Mobile Food Unit <br />l <br />Temporary Food Facility <br />Special Event <br />Dates of 0perati.n <br />from <br />to <br />Dates of Operation <br />from <br />LO <br />1A7ARnn11S WASTF PROGRAM (2200} <br />I Tons generated per year <br />dors Waste Generator <br />I Categorically authorized Categorically Exempt Permit by Rule <br />I Permit Facility <br />ROUSING PROGRAM {2400} <br />I Number of Units <br />Hotel/Motel <br />Jail or Exempt Institution <br />110n[n WASTE PRnr:RAM 142001 <br />tMPLOYEE HOUSINti 1 G / UU f <br />of Employ... Dairy Employee Housing <br />conte Dates of Orr-upancy <br />to <br />I Rflgistrntion A 1 LI('.9109 A 1 Capacity I Vehicle A <br />Pumper Vehicle <br />l Number of Units <br />Punt ler Yard Package Treatment Plant Chemical Toilets <br />MEDICAL WASTE PROGRAM {4500} <br />Primary Care <br />Acute Care <br />Skilled Nursing <br />Lar a Generator <br />Sinall Generator <br />Transfer Station <br />Limited Hauler <br />Veterinary Clinic <br />I> 60 generators <br />Common Storage Facility 1 2- 10 generator. I 1 1 - 60 generators I <br />jFrRFATInNAI HFAI TH PROGRAM 136001 <br />EN, <br />S a Out of Service Pool/S a Natural Bathin Area <br />er of Pools/Spas at Facility PoollSpa ID p <br />CrTF MMGATInN PRnr-RAM 129001 <br />amental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br />1 Cal EPA - RWQCB 1 Cal EPA - DTSC I US -EPA <br />Lead Agency Site l- I <br />1 NPL Site I Water Quality Site 1 Other <br />t , r <br />SOLID WASTE PROGRAM {4400} <br />Landfill Transfer Station <br />A/CanneryAq/Cannery Waste Site <br />CIA Landfill Site Sludge/Ash Site <br />Compost Facility <br />Number of Units <br />Refuse Vehicles <br />Waste Tire Facility Process/Recycle Facility <br />Duni stern >20 cu yd Number of Units <br />VECTOR CONTROL PROGRAM {4000} <br />Maximum Number of Birds <br />Poultry Farrel <br />Energency Notification for this FACILITY and/or PROGRAM <br />if"- rArr Dcncnru- <br />Kennel <br />Day Night <br />Designated <br />Employee # <br />Program Element <br />M^ <br />Current Status <br />Number of Units <br />EP /ioO J w 70 {poets i•� <br />eeeive <br />y ate <br />Reviewedy <br />ate <br />nng Office ate <br />ccouu <br />nit clerk <br />Unit t la <br />