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SJ COUNTY PHS-ENVIRONMENTAL HEALTH Dr& MASTERFIL ORD INFORMATION FORM{EH 00 59(Revised 6/941} <br /> New EH Program/Existing Facility New EH Program/New Facility Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY 0D # REC60D ID # <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applioabi <br /> DAIRY PROGRAM {2000) <br /> Grade A Dairy Grade 8 Dairy Milk Dispenser Number of Containers in Mold-Heed Unit <br /> FOOD PROGRAM {1 6001 <br /> I Seating Capacity I Square Footage <br /> Restaurant Produce Stand Ice Plant <br /> I with Food Preparation Number of Units <br /> 1 Dry storage only VendinG Machines <br /> Commissar <br /> 1 Square Footage I with Meat Market only B with Food Preparation 1 Dry Goods only <br /> _ Retail Market , r r ' <br /> t Make i Vehicle Type ° color t Registration! ° Ucense! <br /> Food Vehicle <br /> i Make t Vehicle Type ° color t Registration! t Ucarise! <br /> Moble Food Unit t t t t t <br /> =.I <br /> od Facility Special Event <br /> from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> Hazardous Waste Generator t <br /> Tons generated per year <br /> Tiered Permit FacilityCategorically authorized Categorically Exempt Permit by Rule <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Units Number of Eteployaee Dalry Employee Housing <br /> Hotel/Motel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution to <br /> U@UID WASTE PROGRAM {4200} <br /> r Vehicle <br /> t, t Registration ! t Ucense! 1 Capacity I VeMale! <br /> Pumpen ' <br /> Pumper Yard Package Treatment Plant Chemical Toilets Number of Units <br /> MEDICAL WASTE PROGRAM {4500) <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facilityi 2-to generators i t t-so generators >60 generators <br /> RECREAnONAL HEALTH PROGRAM {3600} <br /> Pool S a Out of Service PooUS a Natural Bathin Area <br /> Number of Poole/Spas et Facility -4 Pod/spa l0 <br /> d ! <br /> SITE MmGAnON PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat-Pipeline <br /> t Cd EPA-RWGCB B Cal EPA-OTSC I US-EPA <br /> Other Lead Agency Site 1 I I - <br /> 1 NPt.Site l Water Quality Site t other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station —AgLCannery Waste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of Units <br /> Waste Tire Facility Process/Recycle Facility Dum stens >20 cu yd Number of Units <br /> VECTOR CONTROL PROGRAM {4000} <br /> Poultry Farm Maximum Number of Birds Kennel <br /> Emergency Notification for this FACIUTY and/or PROGRAM Day Night <br /> CONTACT PERSON! f <br /> Designated Employee! 1 0 Program Bement! f�Q�t steam Number of UnitsI EPA ID!Lf 4 : <br /> .x:eive y onto eviewed by Date Accounting Office Date Unit Clerk Date Unit Staff oats <br />