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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVISIC MASTIERFILE RE, t INFORMATION FORM {EH 00 691Ra.l..d 01941) <br /> New EH Program/Existing Facility [ New EH Program/New Facility , Date <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> FFFACILITY ID # ''"} t_ rRECORD ID# <br /> Planes Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> _DAIRY PROGRAM {2000} <br /> Gmda A Dalry Grade B Dalry Milk Ell.pen..r Nunbar of Contal.r.In MUNA.ad Unit <br /> FOOD PROGRAM {1 6001 <br /> 1 Seer.,capering 1 6.....Foo... <br /> Restaurant Produce Stand Ice Plant <br /> Commissary Vendin Machines <br /> I Dry Storage only I with Food Prep...don Number of Units <br /> Retail Market 1 Saunre Footnpe I with Meet Market only I with Food Preparation I Dry Good.only <br /> ' <br /> Food Vehicle Make I V.N.I.Type ' colo. ' Rayiatretlon# ' U.....# <br /> I <br /> t Metre ' Vehlole Type ' cola. ' Rapbtretlon# ' U..n..# <br /> Moble Food Unit <br /> Temporary Food Facility Special Event <br /> Date.of operation from to Data.or Operation eom to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> Hazardous Waste Generator ' TO"'a•"B1e0ea per veer <br /> Cebeadoelly av[horlx.d ' Criteporlpnlly 6emp� e^ r � Permit by RW. <br /> Tiered Permit Facility ' E�]'.' <br /> _HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Units FN—'ba:ff DnPI..... Dalry Employee Houslop <br /> Hotel/Moteloxlmeu Dela.of Oapupency <br /> Jail orExempt Institution _ m <br /> _LIQUID WASTE PROGRAM {4200} <br /> Pum er Vehicle ' Re9l.tretlpn # 1 Ucema# I Cepepiry I VeNala s <br /> ' Number of Unita <br /> Pum er Yard Packs a Treatment Plant Chemical Toilets ' <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primer Care Acute Care Skilled NursingLer a Generator <br /> Shell Generator Transfer Station Limited Hauler Veterinary Clinic <br /> - eenernlm. >60 pam�etora <br /> Common Stora a Facility3-10 pemrotor. 11 60 <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool I Spa Out of Service Pool/Spa Natural Bathing Area. <br /> Nunber of Pool°/Spe.at Faallily Pon1150a ID A <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site ' Cal EPA-RWOCB 1 Cel EPA-DTSC I US EPA <br /> 1 NPL Site 1 Writer otwity site I Olber <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Ag/Cannery Ag/CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Nunber o1 Units <br /> Waste Tire Facility Process/Recycle Facility Dum stere >20 cu yd Nunher of Units <br /> VECTOR CONTROL PROGRAM {4000} <br /> Poultry Farm Maximum Nunber of Bird. Kennel <br /> !minyan.,N.Iftetlnn for this FACIUTY endlor MOOR" Day Night <br /> CONTACT PERSON: I h o/`-l4g _TFIOYy'1 Q,S ( �) 4g8 ' (D U 3 ( ) <br /> D.-oneled Employee# Proplmn Bement A Z?ZS Correel Stet. Number Of Units EPA[ # p <br /> eoerve y raw ° y. rite ...n ny in. 616 nit er ate rat to ate <br />