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SJ COUNTY HIS-ENVIRONMENTAL HEALTH DIVISION MASTERFILE RECORD INFORMATION FORM(EH 00 691Revised 6/941) <br /> Naw EH Progran/Existing Facility New EH Program/New Facility Date <br /> SHADED SECTIONS FDR LocAL USE O � � <br /> ............................................. ................................................................_ ...............................................................: ......._...................._............................................................... <br /> n. <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} ,eA-A1 � , � � � L-,Q.--]Y4,0.1" <br /> Grade A Dalry Grade B Dalry Milk Dispenser Number of Containers In Multi-Head Unit <br /> FOOD PROGRAM {1600} <br /> I Seating Capacity I Square Footage <br /> Restaurant Produce Stand Ice Plant <br /> I Dry Storage only I with Food Preparation Number of Units <br /> Commissar Vendin Machines <br /> 1 Square Footage I with Meat Market only I with Food Preparation I Dry Goods only <br /> Retail Market <br /> Make I Vehlole Type I Color 1 Registration/ I Uoenss T <br /> Food Vehicle <br /> I Make I Vehicle Type l Color 1 Registration/ I Uoense X <br /> Mobile Food Unit I 1 I I 1 <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> lHezardous Waste Generator I Tons geoereted per year <br /> Categorically authorized Categorically Exempt Permit by Rule <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Urdd EA <br /> of Employees Ddry Fmployse Housing <br /> Hotel Motel <br /> mate Dates of Occupancy <br /> Jaz or Exempt Institution to <br /> --I-Daum WASTE PROGRAM {4200} <br /> i Registration p I License X 1 Capacity I Vehlole l <br /> Pumper Vehicle <br /> Pumper Yard Package Treatment Plant IF-Chemical Toilets 1 Number of Units <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Larne Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facilityj 2-10 generators t t-60 generators >60 generators <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool spa Out of Service Pool S a Natural Bathing Area <br /> Number of Pools/Spas at Facility Pod/Bps ID <br /> SITE MrnGAnoN PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site I Cal EPA-RWOCB I Cel EPA-DTSC I US-EPA <br /> 1 NPL Site I Water Quality Site I Other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Canner Waste Site <br /> tl n A / <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number or unit. <br /> Numb r of Units <br /> rocess ec c e Facility Dum stere >20 cu d <br /> Waste Tire Facility P R ( I <br /> w / <br /> VECTOR CONTROL PROGRAM {4000} <br /> Poultry Farm Maximum Number of Birds Kennel <br /> Emergency Notification for thls FACIUTY mid/or PROGRAM Day Night <br /> CONTACT PERSON: ( ) ( ) <br /> pwlplteud Fanployeo• 7777 <br /> aont+l, ./ ur �tt Numbor of UMu EPA tD <br /> _. <br /> i <br /> soa ve et :::.:s;>: waw area.. :.:: .: OUAun.a o1ls:;:;«•;>:;:; :;:::;>;:>::#: ::: t. o a:::::;:;:;::;:;:•r':> ty;.a>w..:;; t: to <: <br /> y Y.... ...:: 0 .:...:::::::.:; ...... <br /> .... . <br /> :.:: <br /> . ... . ....... <br />