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y SJ,COUNTY PHS-ENVIRONMENTAL HEALTH DIVISMASTERFILEFMD INFORMATION FORM(EH 00 691Reevised 6/941) <br /> New EH Program/Existing Facility New EH Program/New Facility Data =.2.77 b <br /> SHADED ECT/ONS FOR LOCAL USE ONLY <br /> FACILM <br /> WORD:_ #:... <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 Dairy Milk Dispenser Number of Containers In Multi-Head Unit <br /> FOOD PROGRAM {1 6001 <br /> I Seating Capacity 1 square Footage Produce Stand Ice Plant <br /> Restaurant <br /> I with Food Preparation Number of Units <br /> I Dry Storage only <br /> Commissary Vndina Machines <br /> 1 Square Footage I with Meat Market only I with Food Preparation I Dry Goods orgy <br /> Retail Market <br /> 1 Make ; Vehicle Type I Color Registration# Uoense# <br /> Food Vehicle 1 <br /> Make I Vehicle Type Color Registration# Uoense# <br /> Mobile Food Unit <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> I <br /> Tons en per year <br /> ear <br /> g <br /> Hazardous Waste Generator <br /> Categorically authorized Categorically Exempt Permit by Rule <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700) <br /> I Number of Units Number of Employees Dairy Employee Housing <br /> Hotel Motel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> I Registration# I Ucense# I Capacity I Vehicle# <br /> Pumper Vehicle <br /> Pumper Yard 11 <br /> Package Treatment Plant Chemical Toilets 1 Number of Units <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 Facility1 2 .10 generators 11-SO generators >60 generators <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Spa Out of Service Pool S a Area <br /> Number of at Poets/Spas Facility 00 19 Itfx <br /> N <br /> SRM MITIGATION PROGRAM {2900} diff <br /> -- 17IUZ70 <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site 1 Cel EPA-RWQCB 1 Cel EPA-DTSC SAN JOAQC] NP . <br /> 1 NPL Site 1 water Quality site HEALT fP"RVICES <br /> SOLID WASTE PROGRAM {4400} I ION <br /> C <br /> Landfill <br /> Transfer Station A / anner Waste Site <br /> CIA Landfill Site Sludge/Ash Site Compost acility Refuse Vehicles Nunbsr of urge <br /> Number b of Units <br /> " <br /> Dum star <br /> s >2 <br /> Waste Tire Facility <br /> ProcesslR <br /> ec cle Facility 0 cud <br /> VECTOR CONTROL PROGRAM {4000} d <br /> Poultry Farm Maximum Number of Birds Kennel <br /> Emergency Notification for this FACIUTY and/or PROGRAM ' I Day Night <br /> CONTACT PERSON: f �Ua� ( 1 - 3 <br /> tNNynaad EmMoY±�+f }}ff" "" Wa4ram w... Y Curcrnt!<tetu► Ntr►tber 0CUWa: F�ktG* <br /> I/ .,. <br /> M v ':y. ate;:: gt,oW6 t0 uh qg Of a t t:.tp.:i. Ott <br />