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SJ COUNTY PHS -ENVIRONMENTAL HEALTH DIVI' - 3 — MASTEI FI R�RMATION FORM {EH 00 59fR.rie.d 619411 <br /> New E". P.ogram/Fxisting Facility r New EH Program/New Facility Date <br /> SHADED SECTIONS FOR LOCAL,USE ONLY r <br /> FACILITY ID # v RECORD ID # / /� " <br /> Please Mark the Appropriate Description and Specify Size end/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} <br /> G1adw A DnirY Grrlde B Dairy Milk Dispens.r Number of Containers in Multi-Head Unit <br /> FOOD PROGRAM {1 6001 <br /> 1 se.ung c peciry I Sgunre Footage Produce Stand Ice Plant <br /> Restaurant <br /> I 0"51nrn only I —11,F,xo4 Preparation Number of Unite <br /> Comrttissar Vendin Machines <br /> I 5qunrw Fa two. 1 with Ment Mn.k.1 only f with Food Pr.paredon 1 Dry Good.only <br /> Retail Market <br /> I MMrw 1 V.hide Type 1 Color ; Reglenneon S ; U**ne. <br /> Mobile Food Unit 0 <br /> Food Vehicle i I I <br /> I M.1k. 1 V.W.J.Type I Color 1 R.Osnadon 0 1 uoen..0 <br /> I <br /> 1 I I I I <br /> I <br /> E.,.n7,p-rary Food Facility Special Event <br /> peration frorn to Dat"of Operation from to <br /> HAZARDOUS WASTE PROG M {2200} J f <br /> I Ton.generated per year <br /> Hazardous Waste Generator <br /> Categorically nuthorized Cmegodcally Exempt P.—It b ft bft <br /> Tiered Permit FacilityI <br /> HOUSING PROGRAM {240 01 EMPLOYEE HOUSING {2700} x478 <br /> Dai Employ.*Hou.ln II <br /> 1 Number of Units Number of 6noloy"9 ry <br /> Hotel/Motel <br /> Approximate Dat"of Occupancy <br /> Jail or Exempt Institution ° <br /> LIQUID WASTE PROGRAM 42001 <br /> 1 R.gistrndon I ucemw t 1 C.onciry t Vehicle 0 <br /> Pumper Vehicle <br /> N—b.of Units <br /> Pumper Yard Package reatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRA {4500} <br /> Primary Care Acute Care Skilled Nursin Large Generator <br /> Shall Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 11 <br /> I 2-10 generators I 11-60 gennelon >60 gen.reton <br /> Common Storage Facility <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> pool S a Out of Service Pool/Spa Natural Bathing Area <br /> Number of PoolslSp" et Facility Pool/Spa 10 0 I, <br /> SITE Mmr.AT10N PROGRAM {2900} <br /> I <br /> Environmental Assessment USTXAP Local Haz Waste Haz Mat Pipeline <br /> 1 Cal EPA-RW QCB I Cni EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Site I Water Quakty site I Other <br /> SOLID WASTE PROGRAM 144001 <br /> i <br /> Landfill Transfer Station A /C er Waste Site <br /> Number of Units <br /> CIA Landfill Site Sludge/Ash Site Compost Facility efuse Vehicles I, <br /> Number of Units <br /> Waste Tire Facility Process/ ec cle Facility um sters >210 cu yd <br /> VECTOR CONTROL PROGRA W {4000} <br /> Maxim Number of llirrl \4" Kennel <br /> Poultry Farm ao <br /> 6n.rgency Notilication for this FACILITY nrwllor PIROGRAM O Dwy Nlght <br /> CONTACT PERSON: <br /> =by -ffl)e <br /> Program Bement 0 - .:urr tat Numbs of Units EPA ID 0 R.vrewe by ate Accuunnng����OOyffice su ut C erR .te titStaffate <br /> VII/ <br />