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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIV MASTERFI ''RD INFORMATION FORM^^(EH 00 59(Reele di a/A41) <br /> New EH Program/Existing Facility r New EH Program/New Facility II Date j <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILITY ID # � _i RECORD ID # < <br /> Please Mark the Appropriate Description and Specify Sae end/or Number of Unite where applicable: <br /> DAIRY PROGRAM {2000} <br /> Grade A Dairy Grade 8 Dairy Milk DlsWnser Number of Cont.— In MurJd-Flead Unit <br /> FOOD PROGRAM (1 600} <br /> I <br /> ' Restaurant <br /> Sentinc Capacity Square Footae <br /> Produce Stand Ice Plant <br /> Commissary <br /> oo <br /> I Dry Storage only 1 with Fd Preparation Vendinq Machines <br /> Nv ber of Units <br /> I <br /> I Square Footage <br /> 1 with Most Market only I with Food Preparation I Dry Goods only <br /> Retail Mairket <br /> Make i Vehicie Type I Color I ,.givratioa 0 i Uoeroe S <br /> Food Vehicle I l <br /> I <br /> Make I Vdide Type <br /> Color i Repatrntion / ; U.- <br /> Mobile Food Unit I I <br /> Temporary Food Facility [,-,as <br /> ecial Event <br /> Dntes of operation from to of Operadon from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> i <br /> l Tom generated per year <br /> Hazardous Waste Generator <br /> Categorically authorized Categoricallyui Exempt Permit by Re <br /> Tiered Permit Facilityl <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Unite Number of Employees Dairy Employee fioueing <br /> Hotel/Motel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution to <br /> UQUID WASTE PROGRAM {4200} <br /> I Regia[radon a/ I Ucens• 0 I C.P city 1 Vehid• f <br /> Pumper Vehicle <br /> Number of Uri" <br /> Pumper Yard Packs a Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> I <br /> PrimaryCare Acute Care Skilled Nursin Large Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 2-10 generators 11 -60 g.—,.I.,. >60 generators <br /> Common Storage Facility I <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool I Spa Out of Service Fool/Spa Natural Bathing Area <br /> Number of PoolalSpa• at Facility Pooilspa ID 0 <br /> SITE MMGATION PROGRAM {2900} — <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> I Cd EPA-RWOCB I Cal EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Site I Water Quality Site I Other <br /> SOUD WASTE PROGRAM {4400} <br /> Landfill Transfer Station Ag/Cannery Ag/CanneryWaste Site <br /> Number of Univ <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> I <br /> Number of Units <br /> Waste Tire Facility Process/Recycle Facility Dum stere >20 cu/ d <br /> VECTOR CONTROL PROGRAM {4000} ��}} ✓ '�� P ti!�, r 'y�S to o� <br /> Poultry Farm <br /> Maximum Number of Birds JiyF V Kennel <br /> Emergency Notification for this FACIUTY end/or PR <br /> OGRAM Day�J/� Night <br /> CONTACT PERSON: ��� G ( ) (✓ "r `� ( ) 3�6( <br /> E,ic <br /> gnated 6nployee# Program Element if Current Status Number of Units EPA ID 7 - <br /> r <br /> ,ed y ate` R. w• y els Accounting Office eu nt Isr eu nt to ate <br />