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Irli+-Z Ckw1fAIA 4fizz <br /> SJ COUNTY PHS-ENVIRONMENTAL HEALTH DNIS MASTERFILE P TD INFORMATION FORM {EH 00 691Ra.i.ea SI94)) <br /> rrNew EH Program/Existing Facility New EH Program/New Facility Data1 11 <br /> SHADED SECTIONS FOR LOCAL USE ONLY FF p <br /> FACILITY ID # RECORD ID # IDQ <br /> please Mork the Appropriate Description and Specify Sze and/or Number of Units where Applicable: <br /> DAIRY PROGRAM {2000} <br /> Gentle A Dairy Gred.B Dairy Milk Dispenser Number of C.M.inar.In Multi-Head Unit <br /> FOOD PROGRAM {1600} <br /> I Sontag C.P.dw I Square Footage <br /> Restaurant Produce Stand Ice Plant <br /> Commissary I Dry Ston..only I wRh Food P......don VBodIDG Machines Number or unit. <br /> Retail Market 1 Square Footage I with Meet Market only 1 with Food P,.p.rnaon I Dry Good...I, <br /> I Make I Vebl.le Type I Color I fl.gletreNon # 1 U.....Jr <br /> Food Vehicle I I I 1 <br /> Make I Wed.Type I Color I Degi.tmaan # I License# <br /> Mobile Food Unit I I I I 1 <br /> Temporary Food Facility Special Event <br /> D.tes of Operation from to Data.of Opeagon from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> -Hazardous Waste Generator 1 Tons generated per year <br /> Tiered Permit Facility <br /> Caagodon ly autionizaaC.ugmricelly E.empt Permit by Rule ::�l <br /> _HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> Hotel Motel I Number of UNa Number of Employee. Dalry Employee Housing <br /> Apvraxirnnu Date.of Oucupnnoy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> I Reginretlan f I Ucenae P 1 C....It, 1 Whole Of <br /> Pumper Vehicle <br /> j <br /> Pumper Yard Packs a Treatment Plant Chemical Toilets Wearer of Units <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Larne Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Stora a Facilit i 2-to gamerator. i t t-so ggro r.ra. i >60......tor. <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool I spa Out of Service PGoI S a Natural Bathing Area <br /> Nunber of Pcob/Spas at Facility Pod/Spa ID# <br /> SFTE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site I Cd EPA-Ri I CN EPA-OTSC I USEPA <br /> 1 NPL site I Water ouNiq Site 1 eche. <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station AgICannery Ag/CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of Unit. <br /> Waste Tire Facilil Process/Rec cle Facility, Nomba o1 Units <br /> Dum stere >20 cu d <br /> VECTOR CONTROL PROGRAM {4000} <br /> poultry Ferm Maximl.m Nunber of Bird. Kennel <br /> Em...amy Noli r.gen for tins FACILITY amlfnr PROGRAM Day Night <br /> CONTACT PERSON-. ( I ( I <br /> Deaignared EmStar..ployee x Program Deent � /� Current 9tns Nunber of Units <br /> aoaye y Do,. Ftev,.w.d by Data vooun ng 01fio. D.. Unt CI.,k Date Uen staff 1'J aw <br />