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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVISION MASTERFILE RECORD INFORMATION FORM{EH 00 69tRevised a/Gal} <br /> IfNew EH Program/Existing Facility 1 11 New EH Program/New Facility Date <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> oRi] 16#-' <br /> FACILITY <br /> DAIRY PROGRAM {2000} Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> Grade A Dalry Grade B Dairy Milk Dispenser Number of Containers In Multi-Head Unit <br /> FOOD PROGRAM {1600} <br /> 1 Seating Capeolry 1 Square Footage Produce Stand Ice Plant <br /> Restaurant <br /> 1 <br /> Commissar Vendin Machines <br /> Dry Storage only I with Food Preparation Number of Units <br /> 1 Square Footage 1 with Meet Market orgy 1 with Food Preparation 1 Dry Goods only <br /> Retail Market <br /> 1 Make 1 vehicle Type 1 Color 1 Registration 0 1 Uoeme# <br /> Food Vehicle I 1 I 1 1 <br /> 1 Make 1 Vehicle Type 1 Color 1 Registration I 1 Uoeme l <br /> Mobile Food Unit 1 1 1 1 1 <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> Eads Waste Generator 1 Tom generated per year <br /> rmit Facility Categorically authorized Categorically Exempt Permit br Rule <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING (2700) <br /> 1 Number of Units Number of Employees Dalry Employee Housing <br /> Hotel/Motel <br /> Approximate Dates of Occupancy <br /> Ja0 or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> Pumper Vehicle 1 Registration# 1 Ucense s 1 Capacity 1 Vehicle• <br /> Pumper Yard Package Treatment Plant Chemical Toilets 1 Number of unit. <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursina Lar a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility <br /> j 2-10 generators t t-60 generators i >60 generators <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Pool spa Out of Service Pool/Spa Natural Bathina Area <br /> Number of Pools/Spes et Facility Pool/Spa ID ,: �, :< :;. _ Al <br /> SITE MITIGATION PROGRAM {2900} 3, - A&oktt&Si-- i <br /> Environmental Assessment k""". UST/CAP Local Haz Waste Haz Mat Pipeline <br /> 1 Cal EPA-RW QCB i Cal EPA-DTSC 1 US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Site I water Quality Site 1 Other <br /> SOLID WASTE PROGRAM (4400) n <br /> Landfill Transfer Station Ag/Cannery Waste Site <br /> Number of Units <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Number of Units <br /> Waste Tire Faclli Process/Recycle Facility <br /> Dune stere >20 cu yd <br /> VECTOR CONTROL PROGRAM (4000) Z N v• yLl�n� . <br /> Poultry Farm Maximum Number of Birds Kennel <br /> Emergency Notification for this FACIUTY end/or PROGRAM Day Night <br /> CONTACT PERSON: Mawit_ r,.;, b cm 6Av ovt�vh <br /> Doolgriated Employee t proptem E1 ant it Curreift:8tetw Ntttlbor:tif uhia EPA I41 <br /> ea ve y to ev ewe y stere nn hp ori <br /> i6 -; OaOU 0�i nt9: t Otrf h t to ea <br />