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} SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVISI MASTERFILE RE INFORMATION FORM(EH 00 691Revtsed 6194)} <br /> 11 New Of Program/Existing 11 New EH Program/New Facility Date <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> FACILfTY 1D # ( � RECORD �I7 # <br /> le <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM (2000) <br /> Grade A Dairy Grade B Deity Milk Dispenser Number of Containers In Multi-Heed Unit <br /> FOOD PROGRAM {1 6001 <br /> I Seating Capacity I Square Footage Produce and Ice Plant <br /> Restaurant <br /> 1 Dry Storage only I with Food Preparation IF—Vendinq Machines Number of Units <br /> Commissary I <br /> I Squme Footage 1 with Ment Market Doty I with Food Preparation I Dry Goods only <br /> Retail Market <br /> 1 Make 1 vehicle Type 1 Color I Registration X i Ucense# <br /> Food Vehicle 1 1 1 1 <br /> t I I I t <br /> I Make 1 Vehicle Type I Color I Registration# Ucense# <br /> Mobile <br /> and Unit I I 1 1 <br /> t t I I 1 <br /> Temporary Food Facility FDstes <br /> ial Event <br /> Dates of Operation from to of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tons generated per year <br /> Hazardous Waste Generator <br /> I Cntegoricelly authorized Categorically Exempt t Permit by Rule <br /> Tiered Permit Facility... 1 I <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Units Number of Employees Dairy Fmployae He <br /> Hotel/Motel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> 1 Registration# I Ucense# I Capacity t Vehicle X <br /> Pumper Vehicle <br /> I Number of Units <br /> Pumper Yard Packa a Treatment Plant Chemical Toilets <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 /> I <br /> 2-10 generators <br /> I 11 60 generators I >60 generators <br /> 1 t - <br /> Con1111on Storage Facility <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Pool <br /> spa Out of Service Pool/Spa Natural Bathina Area <br /> Number of Pools/Spas at FacilityZZj <br /> Pool/Spa IDX 'I' I <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> I Cal EPA-RWQCB 1 Cal EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Site 1 Water Quality Site I Other <br /> SOLID WASTE PROGRAM {4400} Pd. ®2(.3 . U-1_415919 CY <br /> Landfill Transfer Station Ag/Cannery Ag/CanneryWaste Site <br /> Number of Units <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Waste Tire Facility Process/Recycle Fticilit <br /> Dum sters >20 cu yd Number of Units <br /> VECTOR CONTROL PROGRAM {4000} <br /> Farm Maximum Number of Birds Kennel <br /> Poultry <br /> Emergency Notification for this FACIUTY and/or PROGRAM Day Night <br /> CONTACT PERSON: r <br /> EDesignatedyee# /� ¢ Program dement#�C1Currant Statut Number of UnitsEPA Ip✓y vete C�J Reviews Y ate ,J counting Office ate ru <br /> ate t to ate <br /> I <br />