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'AL42l CriannC.CLN,i La-,VG <br /> SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVISI MASTERFILE Rr TD INFORMATION FORM{EH 00 59(Reyl..d steal} <br /> I[ENew EH Program/Existing Facility New EH Program/New Facility �- <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> FACILITY ID # 007-701 RECORD ID # <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} A -ki 1 - 5A70449 a - 51Y7 <br /> Grade A Daiq Gmde B Delgr, Milk of...o Number of Containers In MJ1141eW Unit <br /> FOOD PROGRAM {1600} <br /> I Sentlma C...o t, 1 Score Foolnae <br /> ' Restaurant Produce Stand Ice Plant <br /> I Ory Ston..only 1 with Food Preprondoo Number of Voll. <br /> Vending Machines <br /> Commissary <br /> Retail Market <br /> 1 Sau.re F...... I with Meet Market mdy 1 with Food Praparatlon 1 Dry Good.only <br /> 1 <br /> Food Vehicle MA. l Verlde Type I Color I gealaratlon# I U.....a <br /> 1 t 1 I I <br /> 1 Mnke 1 V.N.I.Type t Color I R.&I—don # i license e <br /> Mobile Food Unit I 1 1 I I <br /> Temporary Food Facility Special Event <br /> D.m.of operanon from to Dams of op.radon from t. <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> Hazardous Waste Generator I TBn.g.n...led per...r <br /> Tiered Permit Facility <br /> Ceteacricaily authorized Cero...I.aly Exempt Permit by qJe <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> Hotel Motel I Number or UnitsNomber of Empi.yee" DA,E ,lm,. Hoo"ino <br /> Jail or Exempt Institution Approximate D.m.or OCCnponcy to <br /> LIQUID WASTE PROGRAM {4200} <br /> Pum er Vehicle 1 R.ahb"don # 1 Uo.m.# 1 capacity 1 v.Nde# <br /> Pumper Yard =1 Packs a Treatment Plant Chemical Toilets Number of Unity <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Lar a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facilityj -to pan.ramr. 11-so aBn.rmor. i >so......mi. <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool- Site Out of Service Pool S a Natural Bathing Area <br /> Number of Po09ISpa.at Facility Pool/Spa ID# <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Hat Waste Hat Mat Pipeline <br /> Other Lead Agency Site 1 Cd EPA-RWGCB I CA EPA-DTSC US-EPA <br /> 1 NPL&m 1 Water Godity site I 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 vain <br /> Waste Tire Facility Process/Recycle Facility num stere >?n cu yd Number or Unit. <br /> VECTOR CONTROL PROGRAM (4000) <br /> Poultry Farm Maximum Number of Bird. Kennel _ <br /> Em.......Nodficellon for this FACILITY end/or PROGRAM Day Night <br /> CONTACT PERSON: ( ) ( ) <br /> Desiaruted Employee• Pmgram Bement# ` Current Statue Number of thrift EPA ID 1 <br /> Z z T /: L >J <br /> ecave y era eviewe.. y .le aooun na Be Ble mt er ate tat b ep <br />