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SJ COUNTY nHS-ENVIRONMENTAL HEALTH DNISI MASTERFILE RF 'D INFORMATION FORM(EH 00 591Rarteed Wadi) <br /> New EH Program/Existing Facility New EH Program/New Facility Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY A33 a, 3 <br /> FACILITY ID # 11 <br /> RECORD ID # —5_*K5-' 15041P ,7 _. <br /> Please Mark the Appropriate Description and SpeoifyS=e arldlo�Number of Unita where applicable: <br /> _ DAIRY PROGRAM (2000) a3 S <br /> Grade A Dairy <br /> Grade B Dairy Milk Di.a.n.er Number of Cantai.a.in M.Itl Head UMt <br /> _ FOOD PROGRAM {7600} <br /> I S.adag cepaMly 1 6.....pooa.g. Produce Stand Ice Plant <br /> Restaurant <br /> I with Food P1.Parndon Number of UMI. <br /> I Dry smrng.muv Vending Machines <br /> Commissar <br /> 1 5 Footage I with Moor Market only I with Food Pratl <br /> e.r. cn I Dry G..de oMr <br /> Retail Markel .��are <br /> I Mak. I V.Wcle Typo I Color 1 RedeOnlion ! Ucanee# <br /> Food Vehicle + I r <br /> I Mnk. ; VeNcl.Type Color Regleuegon a ; U..ars# <br /> Mobile Food Unit I <br /> Temporary Food Facility Special Event <br /> Oetaa at Operetlon P., to Data.of Op.ratlon from t• <br /> _HAZARDOUS WASTE PROGRAM (2200) <br /> I Tone son...ted per year <br /> Hazardous Waste Generator <br /> I CntagorlcMly eurhmlzed Categorically Exempt , 2 Permit by Rule <br /> Tiered Permit Facilit <br /> _ HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700) <br /> 1 Number of UMb Nunber of DnPI.y... Dairy Employee Mauling <br /> Hotel Motel <br /> gppro.im.te Dates of ow.,xt oy <br /> Jail or Exempt Institution to <br /> _ UQU1D WASTE PROGRAM {4200? <br /> I Raplarndon #' I Ucena# 1 capacity 1 VeM1icle# <br /> Pum er Vehicle <br /> N.b.,of UMb <br /> Pumper Yard Package Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primer Care Acute Care Skilled NursingLarge Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> I 2.10 generator. 11 -60 generalon >60 generator. <br /> Common Storage Facility I <br /> _ RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool I Star Out of Service pool/Spa Natural Bathina Area <br /> ryootoo at Prtot.ispss at Facility PaWSP.ID# <br /> SITE MlITIGATION PROGRAM {2900) <br /> Environmental Assessment USTICAP Local Haz Waste Haz Mat Pipeline <br /> I Cal EPA-RWQCB 1 CM EPA-DISC I US-EPA <br /> Other Lead Agency Site <br /> I NPLSII. I Water totality alae I Other <br /> SOLID WASTE PROGRAM {44001 <br /> Landfill Transfer Station Aq/Cannery A /CanneryWaste Site <br /> Number of Units <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehiclea <br /> Number of Units <br /> Waste Tire Facility Process/Recycle Facility Dum stare >ZLEIL d <br /> _VECTOR CONTROL PROGRAM {4000) <br /> Poult[y Farm Mnxi,aum N°'°bar of Bird. Kennel <br /> Era;.....Nodapadon IPr this FACIUTY and/or PROGRAM Dnr/// Night <br /> CONTACT PERSON: (tJ'(�(„ ( ) Dt7' 6 7 C ( I <br /> Designated Dnployee A Program B.mehtN�' Ai Current Statue Number of Unin <br /> eneive y .te evewe y ate VJ c°°unbng O me are Uall .daxta rvaC m"L W me <br />