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30(d W .Cxrow�-rltrvi ��t_ <br /> SJ COUNTY PHS-ENVIRONMENTAL HEALTH DNIS' MASTERFILE R' RD INFORMATION FORM(EH 00 69(Reyt..d areal) <br /> l� New EH Pro ram/New Facility (�' <br /> New EH Pragrem/Existing Facility I 9 Y ate— <br /> SHADED SECTIONS FOR LOCAL USE ONLY 3 3 2 <br /> FACILITY ID # co RECORD ID # 50`Oq✓6 <br /> Planes Mark the Appropriate Devoription and Specify SS=e and/or Number of Unit,where epplical,16 <br /> _ DAIRY PROGRAM (2000) 50(.0 � <br /> Grntle A OMry Grade a DO, Milk Ohpeneer Nomb,r of Container.In MAfI-Head Unit <br /> _ FOOD PROGRAM {1600} <br /> 1 s...ng Capacity S......Farm'. Produce Stand Ice Plant <br /> Restaurant <br /> I Dry storage only I with Food PreparationNunber of Unita <br /> Commissar Vendin Machines <br /> I square Fgotnge 1 wilM1 Ment Market only <br /> I with Food Preparation I Dry Goods only <br /> Retail Market <br /> 1 Mak, Vehicle Type <br /> I1 IR.aatman <br /> Food Vehicle ♦ ua.n..a <br /> 1 Make 1 VaNcle Type Color R,geirpro n R Uae.w.a <br /> Mobile Food Unit 1 <br /> Temporary FoodFacility Special Event <br /> Data,of Opmati.n flora to oat..ar operation from to <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> 1 Tons goan.Ne per veer <br /> Hazardous Waste Generator <br /> I Categorically nuthoized Cau.aricnllY E,empt Permit by Rule <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number Of Unit, Number of Fmpiaye,. Dalry Employee Housing <br /> Hotel Motel <br /> Approdovte Dates of 0...Paper <br /> Jail or Exempt Institution t° <br /> LIQUID WASTE PROGRAM {4200} <br /> I Registration a 1 Want.A I capacity i VaM1I=la A <br /> Pum er Vehicle <br /> 1 Nlmber of Unit.Pumper Yard Package Treatment Plant Chemical Toilets f <br /> MEDICAL WASTE PROGRAM {4500) <br /> Primer Care Acute Care Skilled NursingLer a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 2-10......tors 11 -60 g,lwratgr, >60 ae....to,. <br /> Common Store a Faclit 1 <br /> RECREATIONAL HEALTH PROGRAM {3600) <br /> pool S a Out of Service PoolIS12a Natural Bathing Area <br /> Nunber of Pool.lSpes at F—iliry Pod/spa IO A <br /> SITE MMGATION PROGRAM (2900) <br /> Environmental Assessment USTICAP Local Haz Waste Haz Mat Pipeline <br /> 1 Cel EPA-RWOCS 1 Cd EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Site I Water GoAlw site I other <br /> SOLID WASTE PROGRAM (4400) <br /> Landfill -Transfer Station A /Canner Waste Site <br /> Number of Unita <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Waste Tire Facility Process/Recycle cle Facilit <br /> Dura stars >20 cu d Nwnber of Ural. <br /> VECTOR CONTROL PROGRAM {4000} <br /> Ma.imurn Numb,/of ands Kennel <br /> Poultry Farm <br /> Enroll..y Nodgcedon for this FACWTY and/or PROGRAM DRY Night <br /> CONTACT PERSON= ( I ( I <br /> E <br /> yee R Program..meat A ` Current statue I lei Number or UMts FPA ID/J iRle .views y ate C.....do,Offica Data. M[Clerk Data Unit StAff Dole <br />