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f�ON v Cpm <br /> SJ COUNTY PHS E VI NMENTAL HEALTH DIVW MASTERFILE RE ID INFORMATION FORM(EH 00 59M.,risad srsal) <br /> New EH ProgranllExisting Facility New EH PrograrnlNew Facility Dote <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY ID # F RECORD ID # <br /> Plense Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} <br /> Grade A Dairy GTIOd R Dairy Milk Dispm.snr Number of Containers in Multi-Hnad Unit <br /> FOOD PROGRAM {'I 600) J <br /> I S9ating Capaelry I Square Footage <br /> Restaurant Produce Stand Ice Plant <br /> I Dry Storage only I with Food Prepmatimr Number of Unite <br /> Commissar Vendin Machines <br /> 1 Sgome Fun txge I wfih Menl Market only I with F—i Prepa.atinn I Dry code only <br /> Retail Market <br /> Food Vehicle <br /> Mnkn 1 Vithicle Typx I Color I Regietratian p I Ucenae <br /> I t I I I <br /> Make I Vehicle Type I Coh r I Registration 0 I License A <br /> Mobile Food Unit I t I 1 I <br /> Temporary Food Facility Special Event <br /> Dxtes 0 Op—lion r....n to Dotes of Operation from to <br /> HAZARDOUS WASTE PROGRAM {22.00} <br /> Hazardous Waste Generator 1 Tone generated par yenr <br /> Tiered Permit Facility <br /> m <br /> Cegoricafry —11-0-1 c.tegod.0y Exempt Permit by Rule <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> Hotel/Motel I Number of Unit. Number of F—ployees DxllY Employee Housing <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> 1 Regisnntinn tr I LJcr,nse p I Cnpecity I vehirle M <br /> Pumper Vehicle <br /> o <br /> Pumper Yard Package Treatment Plant Chemical Toilets Number f Units <br /> MEDICAL WASTE PROGRAM {4500} <br /> Prifnar Care Acute Care Skilled Nursing Large Generator <br /> Small Generator Transfer Station Litnited I-lauler Veterinary Clinic <br /> 2-10 generators 11 -60 gonnratn rx X60 ganeratgrx <br /> Common Storage Facility <br /> RECREATIONAL "EALTti PROGRAM (3600) <br /> L-7111-1 <br /> S1a Out of Service Pool1S a Natural Bathin Area <br /> f P-1.1Spas nl Fxciliry pon115pa ID p <br /> $ITE MU"GATION PROGRAM {2900} <br /> Environmental Assessment USTICAP Local Haz Waste Haz Mat Pipeline <br /> I Cal EPA RWOCR I Cel EPA-DTSC I US EPA <br /> Other Lead Agency Site <br /> I NPL Site 1 water quality Site 1 Other <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 Number of UNni <br /> Waste Tire Facility Process/Recycle Facility Du1n stens >20 cu yd Numb-of Unite <br /> VECTOR CONTROL PROGRAM {4000) <br /> Poulvy Faun Maxhnum Number of Birds Kennel <br /> Emergency Notiltcntion for this FACIUTy andlor PROGRAM Day Night <br /> CONTACT PERSON. <br /> Designated Ern ployaa# program Dement# f� Currant Slates Nwnhet of Uni[s �P 10 ae <br /> —;e—d byRbm. Reviewer by Date cceunhng G five rale Vuit Clerk D.I. Urit Staff Date <br />