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SJ COUNTY PHS•ENVIRONMENTAL HEALTH DIVISIOI'- MASTERFILE RECORD INFORMATION FORM{EH 00 69(aevised a/aal} <br /> New EH Program/Existing Facility C New EH Program/New Facility Data S <br /> SHADED ,SECTIONS FOR LOCAL USE ONLY <br /> FACILITY ID # RECORD ID # <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Unite where applicable: <br /> DAIRY PROGRAM {2000} <br /> Grade A Dairy Grad.B Dairy Milk Di.1... r Number of Container.in Multi-Head Unit <br /> FOOD PROGRAM {1600} <br /> 1 Seating Capacity 1 Square Footago '1 <br /> Restaurant � -5 Ox "7, Produce Stand Ice Plant <br /> 1 Dry St—g.only I with Food Preparation Numbnr of Unit. <br /> Commissar Vendin Machines <br /> 1 Square Footage I with Moat Market only I with Food Preparation I Dry Good.only <br /> Retail Market <br /> Make I V.hlcln Type I Color 1 Rogistrodou N 1 U..n..N <br /> Food Vehicle I I 1 I 1 <br /> Make I V.bicle Type 1 Color I Registration# I U..n..N <br /> Mobile Food Unit 1 1 I I f <br /> F <br /> morary Food Facility Special Event <br /> t..of Opora tion from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200) <br /> 1 Ton.generated per year <br /> [[Hazardous Waste GeneratorCategorically authorized Categorically Exempt Permit by Rule <br /> iered Permit Facilit <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Unita Nwnber of Ernpioyeas Dalry Ernployae Housing <br /> EHolelel <br /> Approximate Dates of Oocupenoy <br /> empt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> Registration N t Ucenso N 1 Cnp.clty I Vehicle N <br /> Pumper Vehicle <br /> Pumper Yard Package Treatment Plant Chemical Toilets Number of Unita <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Lar a Generator <br /> Shall Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facilityi 2-10 generators 11 -60 generators >60 generators <br /> RECREATIONAL HEALTH PROGRAM f3600 <br /> E <br /> olS a Out of Service Pool/S a Natural Bathin Area <br /> nher of Pocls/Spas nt Fnciliry 4 Pool/Spa IDN <br /> SITE MFFIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site I Cnl EPA-RW QCB I Cal EPA-DTSC I US-EPA <br /> 1 NPL Site 1 water Oualiry Sit. 1 Other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Aq/Cannery A /CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of Unit. <br /> Waste Tire Facility Process/Recycle Facility Dum stets >20 cu yd Numbnr of Unit. <br /> VECTOR CONTROL PROGRAM {4000} 1^ l , �(f <br /> Poultry Farn1 <br /> Maximum Number of Bir/de Kennel <br /> Emergency Notification for this lend/or PROGRAM /�� S J �+ Q y Night <br /> CONTACT PERSON: R.� �� ��.�_ �K 1 — /�l!1 Y IC, Rc� ( '41 <br /> �') <br /> Deaignatod 6npluya.N -� Pregrum Element N i current Storrs Nwnbor of Units EPA ID ar <br /> / <br /> eoatve y ot. Ruvmw.d by ate ceounang we Data art Clarkuta rut to ate <br />