Laserfiche WebLink
SJ COUNTY PHS•ENVIRONMENTAL HEALTH DIVISL MASTERFILE R. '..1D INFORMATION FORM (EH 00 59M.A.ed areal} <br /> New EH Program/Existing Facility New EH ProgramlNew Facility r! - { {� <br /> ��Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY A-* <br /> FACILITY.ID'# RECORD ID # 7 <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} ar3 y sbfa43Lv _-Z1 — 5 937 <br /> Grade A Dairy Grade B Dairy Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD PROGRAM {1 BOO} <br /> 1 Seating Capacity I Square Footage <br /> ' Restaurant Produce Stand I Ice Plant <br /> I Dry Smraga only I with Food Prepamdor. Number of Units <br /> Commissar Verdin Machines <br /> 1 Squarn Fontnga I with RAent Mnrkat only I with Food Preparation t Dry Goods only <br /> Retail Market <br />��o F Make { Vehicle Type I Color F Registration Jr F Ueense 9 <br /> Food Vehicle I f I I t <br /> I Make I Vehicle Type I Color I Reglstrriticn M I LicenseA <br /> Mobile Food Unit I I I I I <br /> Temporary Food Facility Special Event <br /> Dates of Operation Froin to Dates of Operation from - to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> I Toro generated per year <br /> EH.zus Waste Generator <br /> Categorically authorized Cetegorlcally Exempt ^]�i Permit by Rule <br /> ermit Facility (i <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Numher of units Number of Employees Dairy Employes Mveinq <br /> Hot.I'Motel <br /> 771 Approximate Dn[ea of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> I Regiatrn6on A <br /> Pumper Vehicle I Ur"enso A f Capacity t Vehicle N <br /> j <br /> Pumper Yard Package Treatment Plant Chemical Toilets Number of Units <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursina Large Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facilityj 2-10 generators F 11 -So generatofs >60.generators <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> E <br /> S a Out of Service Poo11S a Natural Bathin Area <br /> Pools/Spas at Facility PoollSpn IDA - <br /> SITE MmGmioN PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Met Pipeline <br /> Other Lead Agency Site I Cel EPA-RWOCB 1 Cnl EPA-DTSC I US-EPA <br /> 1 NPL Site 1 Water quality Site I Other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Ag/Cannery,Waste Site <br /> CIA Landfill Site Sludge]Ash Site Compost Facility Refuse Vehicles Ntmtber of Units <br /> Waste Tire Facility Process/Recycle FacilityDum stets >20 cu d Number of Unite <br /> VECTOR CONTROL PROGRAM {4000} <br /> Poultry Farin Maximum Number of Birds Kennel <br /> Fmergancy Notification for this FACILITY andlor PROGRAM Day Night <br /> CONTACT PERSON: ( ) ( } <br /> Designated nyae A Prog,r.am Eeren - ; Current,Stntus nber of Units <br /> E, <br /> ate ..Review ate cauuntrng O liceate : nit Clerk. <br /> EPAfIpt✓r.;.:. 2- <br /> .:. <br /> Receive <br /> te.:,. <br /> , <br />