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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DNISf MASTERFILE Fir i P INFORMATION FORM(EH 00 691R.w..a 61941) <br /> New EH P g it t g F IM1y New EH P g /N Facility r Data <br /> •SHADED SECT/ONS FOR LOCAL USE ONLY <br /> RECORD ID # <br /> FACILITY ID # <br /> please Mark the Appropriate Description and Specify Size and/or Number of Unite where applicable: <br /> _DAIRY PROGRAM {2000} <br /> Grade A Deiry Grade 6 Dalry Milk Dispenser Nimb.r of Container.In Mula-Heed Unit <br /> _ FOOD PROGRAM {1600} <br /> I Beating capacity I Square Foream Produce Stand Ice Plant <br /> Restaurant <br /> Number of unitsI Dry Btomm <br /> ga only 1 with Fooa Prepntlon Vending MBChID88 <br /> comm <br /> issary <br /> 1 Balmu Footage <br /> I with Mee[Market only 1 with Food Prepnretlon I Dry Goods only <br /> Retai <br /> I I patterns..# I Uceme# <br /> I Make 1 vehicle Type 1 color 1 1 <br /> Food I I <br /> 1 <br /> I I Reglelrndon ! 1 Uceme#1 V.14.1.TYPe 1 Cdor 1 <br /> Make <br /> Mobile Food unit <br /> Temporary Food Facility Special Event <br /> Dates of O tion bora to Gams of creation form to <br /> Grant,. <br /> _ HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tons gnwatt.d per year <br /> Hazardous Waste Generator <br /> Categorirelly Exempt/(� 2�� 1 Parmit by Rule <br /> camvracally erthra:.a 1 1 <br /> Tiered Permit Facilit <br /> _HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> - 1 N.b.,of Unit. Number of 6"Ploya.. Deiry Dnployea Hominy <br /> Hotel/Motel <br /> Arprmlmate cam.of opprpanoY w <br /> Jail or Exempt Institution <br /> LIQUID WASTE PROGRAM {4200} - <br /> I veHMe# <br /> Pump V�eh'' <br /> I Registration# <br /> Pumper Yard I Parka a Treatment <br /> _MEDICAL WASTE PROGRAM {4500 <br /> Primary Care <br /> Ac t Ler a Generator <br /> Small Generator Tr1 Veterinary Clinic <br /> Z <br /> 1 >6c genereton <br /> Common Storage Facility <br /> RECREATIONAL HEALTH PROGRAM <br /> Pool S a Natural BathingArea <br /> Nrmb.r of Pod.IBpe.at Facility <br /> _SrTE MITIGATION PROGRAM {2900} <br /> Environmental Assessment U! JUS-EPtA=tj <br /> Pipeline <br /> 1 cx Other Lead Agency Site I_Ice <br /> NP <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station AulCamnery Waste Site <br /> Number of UMb <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Number of UMI. <br /> Waste Tire Facility Process/Recycle FacilityDum stere >10 cuyd <br /> VECTOR CONTROL PROGRAM {4000} <br /> Mesion.N.b.,of Bods Kennel <br /> Poultry Farm <br /> Rampancy Notle.st.. for this FACIUTY andlor MOGRAM Day C� Night <br /> CONTACT PERSON: r ; (CID 1 G� 7 (D� — r •� I , L <br /> Umignated Fop! yes# O�ry�i Program Dement k _� C areal afar a 0s Numbea of Units / VA ID/ 0, <br /> V [/ <br /> eo.... awawa y ale Y ala 7a_o to lbng O ICB ate al. nt G ate <br />