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SJ COUNTY PH5-ENVIRONMENTAL HEALTH DIVISIC MASTERFILE RF( T INFORMATION FORM (EH 00 691Realsetl 61941) <br /> New EH PrograpplExititing Facility Ez:: Nay,EH Progr. /New F 'Irty �VDtrt. <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 Unit where applicable: <br /> _ DAIRY PROGRAM {2000} <br /> O..tle A Dairy Grade B Daily <br /> Milk Dbpenser Number of Container.In Multl-Heed Unit <br /> 7Restaurant <br /> FOOD PROGRAM {1600}seed.,Cepedcy I sq°ere Foo,g. Produce Stand Ice Plant <br /> Nvnbar pf UWb Orr am,ve oNy I wim Food weperatlon Vendin Machines <br /> Square Footage I with Maet Market orgyI with Food Preperetlon I Ory Oootl.oNy <br /> I Meke I VeNWe TypeII MM.. 1 Vairlds Type Color Ra,btretlpm / i D.ems r <br /> 1 1 <br /> I <br /> emporary Food Facility Special Event <br /> .1 operation from to Dates of operation from to <br /> _HAZARDOUS WASTE PROGRAM {2200} <br /> 1 To..9...r.red Per year <br /> Hazardous Waste Generator I 1 <br /> Cate,mledly euthodeed Cete,orlpoly Etempeg ; / I,` •i Permit by Rule <br /> Tiered Permit Facility1 <br /> _HOUSING PROGRAM {2400} _ EMPLOYEE HOUSING {2700} <br /> 1 Number of Units Number of Employees Dalry EmWgyee Houdng <br /> HotellMotel <br /> Approximate Dates or oo.°Pemoy <br /> Jail or Exempt Institution tO <br /> _LIQUID WASTE PROGRAM {4200} <br /> I 0.eplevnd.n A I Ucense r I c...dr, I vehicle r <br /> Pumper Vehicle _ <br /> 1 Number of UNH <br /> Pumper Yard Package Treatment Plant Chemical Toilets 1 <br /> MEDICAL WASTE PROGRAM {45500} <br /> Primer Care Acute Care Skilled NursingLar a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 1 2-10,.....tore 11 -so penem.0 >60 generator. <br /> Common Store a Faclit 1 <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Eva Out of Service Pool/Spa Natural Bathing Area <br /> Number of PoolsfSpas at Fnciliry Pool/Spa ID r <br /> SITE MmaAnoN PROGRAM {2900} <br /> Environmental Assessment I UST/CAP Local Haz Waste Haz Mat Pipeline <br /> I C.1 EPA-MOCK 1 CM EPA-DTSC 1 USEPA <br /> Other Lead Agency Site <br /> 1 NPL Site 1 Wemr Quality kite I 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 Units <br /> Waste Tire Facility Process/Rec cle Facility D,m eters >20 cu vd Number or udN <br /> VECTOR CONTROL PROGRAM {4000} <br /> Poultry Ferro Maximum Number of Bird. Kennel <br /> Fina,emoy N.tl,retkm for tlge FAACCIUTY e.dl., <br /> PROGRAM J Day Night <br /> CONTACT PERSON: I,/0.V l CI 'Pt--u u he I ) 20Cj) 3(DB- 2'�{SS ( ) <br /> Designated Employee d Prov,.Remem N .J - Current etmne Nmnber of Units EPA ID r <br /> ecei y me .m.we y ate p. umng roe lets nu .. n[ , ate <br />