Laserfiche WebLink
SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVAlft MASTERFILE D INFORMATION FORM(EH 00 591Revised 6/94)} <br /> New EH-Program/Existing Facility 1 11 New EH Program/New Facility Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY ID# T ' RECORD Ira# <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-Head Unit <br /> FOOD PROGRAM {1600} <br /> 1 Seating Capacity 1 Squnte Footage —IFProduce Stand Ice Plant <br /> Restaurant r <br /> Number of Units <br /> 1 Dry Storage only I with Food Preparation Vendin <br /> Commissar Machines <br /> i Square Footage I with Meet Market only I with Food Preparation I Dry Goods only <br /> Retail Market <br /> I Make ; Vehicle Type i Color Registration# i license# <br /> Food Vehicle f <br /> Make Vehicle Type Color Registration# i U061190# <br /> Mobile Food Unit <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tons generated per year <br /> Hazardous Waste Generator <br /> Categorically authorized Categorically Exempt Permit by Stile <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Units Number of Employees Dairy Employee Housing <br /> Hotel/Motel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution fO <br /> LIQUID WASTE PROGRAM {4200} <br /> 1 Registration# 1 License# I Capacity 1 Vehicle# <br /> Pumper Vehicle r _I I ' <br /> � Number of Units <br /> Pumper Yard Package Treatment Plant Chemical Toilets <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 /> 2-10 generators 11-60 generators >60 generators <br /> Common Storage Facility I <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Spa Out of Service Pool/Spa Natural Bathina Area <br /> Number of Pools/Spas at Facility Pool/Spa ID# -' <br /> SITE MITIGATION PROGRAM {2900) <br /> Environmental Assessment UST/CAP Local Haz Waste i eline <br /> I Cal EPA-RWQCB I Cal EPA-DTSC I US-EPA <br /> Other Lead Agency Site I Ia7 <br /> I NPL Site 1 Water Quality Site I 41997 <br /> SOLID WASTE PROGRAM {4400) <br /> Landfill Transfer Station A /Canner Waste Site Pl3k3L1C yEA1TH AIXW A.. <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of urtts <br /> um <br /> Waste Tire Facility Process/Recycle Facility Du s >20 cu yd <br /> VECTOR CONTROL PROGRAM 1400 3�D• z v✓. 6. L �f/`132 <br /> 412 <br /> Farm Maximum Number of Bir areal <br /> Poultry <br /> Emergency Notification for this FACIUTY and/or PROGRAM Day Night <br /> CONTACT PERSON: Thomas A. Sanchez Div. Ger.eager) ( Qi9-8274 ( of�111- 71 <br /> Designated Employee# t i'1 Program Element# �erstatus Number dt Uhits EPA Iq i1 -: <br /> /Cl , <br /> 31 <br /> ocervet by Date Reviewed by Date counting office Loate DateStaff Date <br /> G Dqo$ ["U"...... <br />