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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DM MASTEAFILE f RD INFORMATION FORM{EH 00 691asotead 619411 - <br /> �N EH p g 1Fa' t g F 'Iby New EH Program/New Facility I Data < 3 <br /> SHADED SECTIONS FOR LOCAL USE ONLY -3 <br /> FACILITY <br /> 1D # I RECORD ID # ✓� D� :,. �`'�`� - <br /> Please Mark the Appropriate Description and Specify 3S_e end/or Number of Units where applicable: <br /> DAIRY PROGRAM (2000) a <br /> Omde A Dairy Grade a Dairy Milk Discerner Number of Canters.in MOO Head Unit <br /> FOOD PROGRAM {1600} <br /> 1 seethes Capacity I sgn...F...... Produce Stand Ice Plant <br /> Restaurant <br /> 1 Dry Stares°only I with Food Precast.. Vendin Machines Number of Unite <br /> Commissar <br /> I S.uera Footage I with Meet Market only I with Food Ps,rartlon I on Goode only <br /> Retail Marks <br /> Make I Vehicle Type I Color I Regi I-Obr t t J..n.a R <br /> Food Vehicle I I I I <br /> I Make I VeNcla Type I Color I Regi.Vetlan t Up....t <br /> Mobile Food Unit I I 1 I <br /> Temporary Food Facility Special Event <br /> Data.of Operation bnm to Dates of Opernaon Irom to <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> I Tone.....rated par.... <br /> Hazardous Waste Generator <br /> Categorically authorized Caleg.dcelly Exempt // Permit by Rd. <br /> Tiered Permit Facility1 <br /> HOUSING PROGRAM f2400 EMPLOYEE HOUSING {2700} <br /> I Nmnbar of UNts Mnnbar of Employee. Derry Employee Housing <br /> Hotel Motel <br /> APpraxlmat. oma..1 o.onpa,,.y <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200] <br /> 1 flegiehetlo..A 1 U.te ea A I Capacity I Vehicle <br /> Pum er Vehicle <br /> 1 chance,.f Udte <br /> Pum er Yard Packs a Treatment Plant Chemical ToiletsI <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primer Care Acute Care Skilled Nursing Ler a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Stora . Facilit i 2-to generators 11 -so generator. >so'...'roar. <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool I Spa Out of Service PoollS a Natural Bathin Area <br /> Mender,of Pre spipaa at Facility Pod/spa to t <br /> SITE MITIGATION PROGRAM (2900) <br /> Environmental Assessment UST/CAP Local Hez Waste Haz Mat Pipeline <br /> Other Lead Agency Site I CM EPA-RWOCB 1 Cal EPA-DTSC I US EPA <br /> 1 NPL Site 1 water mrelay sit. I Omer <br /> SOLID WASTE PROGRAM {4400) <br /> Landfill Transfer Station Ag/Cannery Ag/CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site ==J Compost Facility Refuse Vehicles N—b.,of Unite <br /> Waste Tire Facilitv Process/Recycle Facilit Dum stere >20 cu yd Number or Unit. <br /> VECTOR CONTROL PROGRAM {4000) <br /> Poultry Farm Maximum Nicobar of Bird. Kennel <br /> Frescoes, N.d6ce6on for this FACILITY entllor PROGRAM Day Night <br /> CONTACT PERSON: (WC7) 3 / ( ) <br /> Designated enployee# progrern Deman Lj Cune t B�rIwJP Number of Unite EPA I I <br /> (�v 3 <br /> ecewe y ata a, Len. me rvtStaffnme <br />