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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVIS' MASTERFILE RF—-3D INFORMATION FORM{EH 00 59(Revi.ed 61941} <br /> New EH Program/Existing Facility New EH Program/New Facility <br /> SHAVED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY ID # RECORD ID # <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000) <br /> Grade A Dairy Grade B Dairy Milk Dispenser Number of Containers in Multi-Hand Unit <br /> FOOD PROGRAM {'I 6001 <br /> 1 S.ntinp Capacity 1 Square Footngn <br /> ' Restaurant t t Produce Stand Ice Plant <br /> Commissar Vendin Machines <br /> 1 with Food Pr. r ti Numbar of Unite <br /> 1 Dry Stnrng.aJy P rra urn <br /> I Sgoam Footngn 1 with Ment M.rk.t Duly 1 with Food Prop—tion 1 Dry Goods only <br /> Retail Market <br /> 1 M.ke I Vehicle Type 1 Color I Regleuntion # ; Ucense# <br /> Food Vehicle I I I I <br /> 1 1 ! 1 1 <br /> 1 Mnk. V.Iricl.Typ. i Color ; R.gi.trmion # ; Ucenea # <br /> Mobile Food Unit I <br /> Temporary Food Facility Special Event <br /> Dot-of Oflernti— Iron to Date,of Op...tial from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> I Ton,p.nnrntnd par y.nr <br /> Hazardous Waste Generator <br /> 1 Categorically authorized Categorically Exempt Permit by Rule <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Vnits Number of Ernployoes Dairy Employee Houeing <br /> Hotel/Motel <br /> Approximate Dates of Occuprrncy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> 1 Regi,trntion # 1 Ucense # I Capacity I Vehicle# <br /> Pumper Vehicle 1 t t ! <br /> I Numbnr nl Units <br /> Pumper Yard Package Treatment Plant Chemical Toilets 1 <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Lar a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 1 2-10 generators 11 -60 pane..tors >60 gene me <br /> Common Storage Facility <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool I Spa Out of Service Pool/Spa Natural Bathing Area <br /> Nwnbar of Pools/Sp.s at F.cility Pool/Spa ID# <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment V O=UST/CAP Local Haz Waste Haz Mat Pipeline <br /> I C.1 EPA-RWQCR I Cal EPA-DTSC 1 US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Sit. 1 Wnt.r Qtmlity,Sit. I othor <br /> SOLID WASTE PROGRAM {4400) <br /> Landfill Transfer Station Ag/Cannery Waste Site <br /> Number of Unita <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Waste Tire Facility Process/Recycle Facility <br /> Dum sters >20 cu yd Number of Unite <br /> VECTOR CONTROL PROGRAM {4000} <br /> Maximum <br /> Poultry Faun Nwnbar of Birds Kennel <br /> 6norpency Nwificaion for this FACILITY and/nr PROGRAM Day Night <br /> CONTACT PERSON: <br /> Eeq,q­;od,E,"pIo ,non Elemen # CurrontStnhts mof Units EPA 10# <br /> ccounng Oce Date Unit Clerk e <br /> ate.. Roviewe y ae <br /> r <br /> Z fL <br />