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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVISK MASTFRFILE RE -1 <br /> J INFORMATION FORM{EH 00 691R.aleed a/sal} <br /> I <br /> N EH P g /Ex t g F IrtV N EH P g IN F 'lily Dole <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY ID # .RECORD ID : <br /> Please Mark the Appropriate D...iPtion and Specify Size end/or Nuln be,of Unite where eppliaable: <br /> _ DAIRY PROGRAM {2000} - <br /> erode A Onby GmAa B Dalry Milk DI.yansor Numbar of Container-In Multi".adUnit <br /> 7Restaurant <br /> FOOD PROGRAM {1600}I saetlng Cepaplry I saner.Footnote produce Stand Ica Plant <br /> 1 with Food Preparation Number of UNbi Dry storage Only Vendin MachinesFoobgo I with Meat Market only1 with Foad Preparation I Dry Ogotl.oNyI Meke I VaNela TYPe 'I -dor ; Reglebetlon R Uaeme R <br /> I Make I Vehicle Type ColorX <br /> I I <br /> Temporary Food Facility Special Event <br /> Dena.of 0,ar.eon from to Do(.$of operation born to <br /> _HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tone generated per year <br /> Hazardous Waste Generator <br /> Wtegorlcelly authorizea CebgorloNlr Exempt Permit by any <br /> Tiered Permit Facili 1 <br /> _HOUSING PROGRAM {2400} _ EMPLOYEE HOUSING {2700} <br /> I Number of Units Number of Dnpl..... nelry Employee Hauaing <br /> HotellMotel - <br /> Appro.nn.l. Data.of 0...P...Y <br /> Jail or Exempt Institution no <br /> _IJOUID WASTE PROGRAM {4200} <br /> 1 raglrtbdon X I U.....R I Cepeclry I VeNcie R <br /> Pum er Vehicle <br /> Number of UnityPum er Yard 1 package Treatment Plan[ Chemical Toilets I <br /> _ MEDICAL WASTE PROGRAM {4500} <br /> PtiM8FY Care Acute Care Skilled Nursino Lar a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 2-10 generators 11 -So generator. >so genemten <br /> Common Storage Facilit I <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Are. <br /> Number of POOH/Sp.a at Facility P..Us,p ID ar <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Hat Waste Haz Mat Pipeline <br /> I Cel EPA-RW GCB I CN EPA-DTSC I UsEPA <br /> Other Lead Agency Site <br /> 1 NPL Site I Water Quality Site I 011ul <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Aa/Cannery Aa/CanneryWaste Site <br /> Numher of UnityCIA landfill Site Sludge/Ash Site compost Facility Refuse Vehicles <br /> Nwnber of Unit. <br /> Westa Tire Facility, Process/Rec cls Facilitv Dum stere >20 cu yd <br /> VECTOR CONTROL PROGRAM {4000} <br /> Maximum Number of Bleb Kennel <br /> Poultry Farm <br /> Dnargency Notification [or tld.FACIUTY endfor PROGRAM Dny NIgM <br /> CONTACT PERSON: <br /> Eye X Program Eh nand �,_, Cprrant 8tmge Number of Uniu FPA ID/ fr,ale -view- y o(. pa.nnfing ma ate pn Data Unit b ab <br />