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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DMS MASTERFILE RI&D INFORMATION FORM{EH 00 691Ravl.ed areal} <br /> New EH Program/Existing Facility I I New EH Program/New Faoility Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY <br /> IDA RECORD (D # <br /> Rates Mark the Appropriate Description and Specify SS=eendlor Namber of Units where applicable: <br /> _DAIRY PROGRAM (2000) <br /> Gretle A Dalry Gmde B Dairy Milk 01....... Number of Crudm.m In Muld-Heed Udt <br /> FOOD PROGRAM {1600) <br /> 1 Searing capacity, I Square Foomge Produce Stand Ice Plant <br /> Restaurant <br /> 1 Dry Store,.only I with Food later11 Number of Units <br /> Commissar Vending Machines <br /> I Square Focus, I with Ment Market only I with Food Preperedon I Dry Good.only <br /> Retail Market <br /> Make Vehlale Type Calor Regl.Oerion A U..... <br /> Food Vehicle i <br /> Mobile Food Ui Make V.hlel.Type color R.gl. s <br /> lmtio.A u..... <br /> ,it <br /> Temporary Food Facility Special Event <br /> Data,of Opamd.n from to Dates of Operation from to <br /> _ HAZARDOUS WASTE PROGRAM (2200) <br /> I Ton.generated par yen, <br /> Hazardous Waste Generator <br /> � categorically eutM1adzed � Cetegad.elly Exempt � Permit by Rule <br /> Tiered Permit Facility <br /> _ HOUSING PROGRAM {2400) EMPLOYEE HOUSING {2700} <br /> I Number of Unita IrApdamdermts <br /> mber of Employs.. Ddry Employee Houslnp <br /> Hotel/Motel <br /> nate.of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200) <br /> I gegietratlon A I Ueanse A I Capacity I VelJole A <br /> Pumper Vehicle <br /> I Number of Units <br /> Pum er Yard <br /> Package Treatment Plant Chemical Toilets I <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled NursingLar a Generator <br /> Shall Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 2-10 Generato,. 11 -60......far. >60gemretor. <br /> Common Storage Facilit I <br /> RECREATIONAL HEALTH PROGRAM {3600) <br /> pool Spa Out of Service Pool/S a Natural Bathina Area <br /> Number of PoolslSpas at Facility, 'vodlSpe ID A <br /> SITE MFHGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> 1 Cel EPA-RWQCS I Cal EPA-DTSC i US-EPA <br /> Other Lead Agency Site <br /> I NPL Site I Water Duality Site I Other <br /> SOLID WASTE PROGRAM {4400) <br /> Landfill Transfer Station An/Cannery An/CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Nmnbarof thethered <br /> Waste Tire FacilityProcess/Rec ele FacilityDum eters >20 cu d Nmnbar,or UNb <br /> _VECTOR C NTRO ROGRAM J4000) <br /> Poultry Farm M i N er of Ir <br /> Emergency Notification for this FAC TY and/or Gq DayOr . <br /> ( g t <br /> CONTACT PERSON: \, ( —1 ('TI ) 9:7✓ /-" ` <br /> De.ign.ted Employee A ProgrMn Demegt B'. Current 8mm! Number of Una FPA ID 0 <br /> e..unra y y DateAo7Was nl Mark Data t. m at. <br /> ^(f <br />