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' z ' 0 I I (� MASTERFILE R TO INFORMATION FORM{EH 00 691Rised III <br /> SJ COUNTY PHS-ENVIRONMENTAL HEALTH DMS' ev <br /> IFNew EH ProgramlF.xisti I r I o:ilitV � IF New EH Program/New Facility Det. <br /> SHADED SECTIONS FOR LOCAL USE ONLY AA3 <br /> FACILITY ID # DDaI l2_ RECORD ID # 571(oSr'/C' <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Unite where applicable: <br /> _DAIRY PROGRAM {2000} <br /> Grade A Dairy Greds B Ddry Milk Disp...r Number of Contdnen In MWd-Heed Unit <br /> _FOOD PROGRAM {1600} <br /> 1 Sears,C....try I sguam Fom fur Produce Stand Ice Plant <br /> Restaurant <br /> 1 with Food Preparation Number of Units <br /> I cry arouses cloy VendingMachines <br /> Commissar <br /> 1 Smuent Formula I with Meet Market only I with Food Preparation I Dry Goode copy <br /> Retail Market <br /> l Make 1 Vehicle Type 1 Color I Reeisbaeom# 1 U..mur# <br /> Food Vehicle 1 1 I 1 <br /> I Make 1 Vehicle Type 1 Color I R.ginnutko A i Upamee If <br /> Mobile Food Unit i 1 I I I <br /> 1 <br /> Temporary Food Facility Special Event <br /> per..o1 opeauhm from m Det..of oinumbon from to <br /> _ HAZARDOUS WASTE PROGRAM {2200} <br /> I Tons aenemt.d per year <br /> Hazardous Waste Generator <br /> 1 Categorically authorized Cano.r..ly Exempt Permit by Rule <br /> Tiered Permit Fecgit I <br /> _HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Units Number of Employee. Ddry Employee H...In, <br /> Hotel Motel <br /> Approximate Deva of Occupancy <br /> Jail or Exempt Institution to <br /> _LIQUID WASTE PROGRAM {4200} <br /> I R.eletmtion IF I Ucenag! 1 C.P.city I Vehicle IF <br /> Pumper Vehicle <br /> 1 Number of UWv <br /> Pum er yard Packs a Treatment Plant Chemical Toilets 1 <br /> _MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursin Larive Generator <br /> Small Generator I Transfer Station Limited Hauler Veterinary Clinic <br /> 2-10..mento, 11-60 genrs erato >60 e.meravn <br /> Common Storage Facilit 1 1 <br /> _RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool <br /> sea Out of Service PoollS a Natural Bathing Area <br /> Number cl Pcols/Spas al Facility PodRpa ID 0 <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> I Cel EPA-RWQCB 1 Cd EPA-OTSC I US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Site 1 Water churiry Sita I Other <br /> SOLID WASTE PROGRAM {4400} <br /> rCl <br /> fillTransfer Station A /Canner Waste Site <br /> Number or UnivLandfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Number of Units <br /> e Tire Facility Process/Recycle FacilityDum stere >20 cu d <br /> _VECTOR CONTROL PROGRAM {4000} <br /> Mention.Number of Birds Kennel <br /> Poulby Farm <br /> Emergency Nadficaeon for this FACILITY and/or PROGRAM Day Night <br /> CONTACT PERSON_ <br /> E <br /> ed Employee k prmpre.E surmt# Currant Status Number of Units Mob <br /> O^ ��/ -1 D <br /> y ate Reviewed y ate copunong ce ate 1111 er ate nt a (� Vr tare <br />