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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DR/ISIO' MASTERFILE REC INFORMATION FORM{EH 00 59(R.vl..d 61941} <br /> New EH Program/Existing Facility T-J'New EH Program/New FooilityDate <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> FACILITY ID # RECORD ID # <br /> Please Mark the Appropriate Description and Specify Size end/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} <br /> Grade A Dairy Grade R Dairy Milk Di.pen... Number of Container.hr MNi-H..d Unit _ <br /> 11 <br /> FOOD PROGRAM {1600} <br /> I Seeing Capaclw I Sauare Feet... <br /> Restaurant Produce Stand Ice Plant <br /> Vending <br /> 1 Dry Storage only 1 with Food Preparation Number of UNu <br /> Machines <br /> Commissar <br /> etail Market I &Rm <br /> use Footage I with Meat Market only I with Food PRep.r.dc. I Dry Good. dy <br /> i <br /> Food Vehicle Make 1 Vehicle Type 1 Color I Regi.eatlon0 I U�...I <br /> 1 1 1 I I <br /> Mobile Food Unit <br /> Make I VeNol.Typo I Color I Reglaallon I I Upmu 1 <br /> 1 I I I I <br /> =Te-po,.,,.yFacility Special Event <br /> from to Data.of Op.r.dmr from 1. <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> I Tom ii.c.elad per year <br /> Hazardous Waste Generator <br /> Tiered Permit Facilityi C.t.goioNly .IanmU.n i C.mgoip.ay Ex.mpCe 'i�1 Permit by not. <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Unlu Number of Dnploye.. Ddry Employee Hou.lny <br /> Hotel/Motel <br /> Jail or Exempt Institution ApProxima4 Detee of opouoanoy m <br /> LJOUID WASTE PROGRAM {4200} <br /> FF-P.-.Zr Vehkle 1 Reglell.ten I I upon.. I 1 capacity 1 Vehicle I <br /> Pumper Yard 11 Package Treatment Plant Chemical Toilets Number or Unn. <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primer Care Acute Care Skilled Nurein Large Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Stora a Facility <br /> I 2-10 generator. 1 t -so generator. >60......tar. <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool spa <br /> Out o/Service Pool/Spa Natural BathingArea <br /> Member of Poolel9p.. et Facility Pool/Spa IDA <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site I Cel EPA-RWOCR 1 Cal EPA-DTSC USEPA <br /> I NPL Site 1 Water Goaller Site 1 Other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Alt/Cannery Alt/CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of uNi. <br /> Waste Tire Facility Process/Recycle Facility Dum eters >20 cu yd Number of UNu <br /> VECTOR CONTROL PROGRAM {4000} <br /> Maximum Nmnber of Birds <br /> Poultry Farm Kennel <br /> Dnelg.rlcy Nodacation for this PACIOTY molcr PROGRAM Day Mibi <br /> CONTACT PERSON: I� U �T2�IMYAE (zogl 823-Ou20 ( ) <br /> Dedgnated Employee A Program Dement A Current Staiu. Nomber of Wdu IPA <br /> eoerye y e,e Reviewed by Data c000nangOffic.. ate Oar Clark Do,. Ulat Staffate <br />