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� MASTERFILE RECORD INFORMATION FORM{EH QO I791Rsriwd e1e41] <br /> SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVISION <br /> New EH ProgranllEnisting Facility New EH Program/New Faoilhy <br /> Dote r �" <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACILII-Y,;IDS #....., <br /> * ..,:; .. . ORS <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DASITY PROGRAM {2000} <br /> wk Dispenser Number of Contstners In Mutd•Hsad Unit <br /> Grads A Dairy Grade 6 Dalry <br /> FOOD PROGRAM {1600} <br /> 1 Seating Cnpaclty I square Footage Produce Stand lee Plant <br /> Restaurant Number of Unite <br /> 1 Dry Storage only I with Food P+eperndon Vpndina Mechlne8 <br /> Commissar <br /> 1 with Food Preparation ! Dry Goode only <br /> 1 Square Footage <br /> I with Meet Market only <br /> Retail Market 1 <br /> :i 1 Maks i Vehicle Typ@ I Color Replstredon S l Uoense <br /> 1 <br /> Food Vehicle I <br /> 1 <br /> Reg <br /> I istration it I Ucsnse i <br /> I make Vehicle Type I Color I 1 <br /> Mobile Food Unit I <br /> y Special Event <br /> Temporary Food FacilityDate, � to <br /> eration <br /> from to <br /> 'l atas of Operation from <br /> ;+ Ontef of Op <br /> . HAZARDOUS WASTE PROGRAM {2200} <br /> I Tons generated Per year <br /> Hazardous Waste Generator I permit by Rul■ <br /> I Categorically authorized Categorically Exempt I <br /> k Tiered Permit FacilityI <br /> • HOUSING PROGRAM {2400} <br /> EMPLOYEE HOUSING {2700} <br /> S 1 Number Of Unlls <br /> Number o!Employees Dairy EmPicyse Housing <br /> HotellMotel <br /> - Appioilmnls Ontas of Ooonpency to <br /> Jail or Exempt Institution <br /> DJaUID WASTE PROGRAM {4200} <br /> � p I Uceme x ! Ca eclty 1 vehicle� 1 RegistrationA <br /> Pumper Vehicle I <br /> I Number of Units <br /> Pum er Yard Packs a Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> primary Care <br /> Acute Care Skilled Nursing Large Generator <br /> Transfer Station Limited Hauler Veterinary Clinic <br /> fi Small Generator ! <br /> I <br /> 1 2-70 generators 71•so generators I 760 Qenetators <br /> � I <br /> Common Stora a Facilit 1 <br /> # RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool <br /> $ a Out of Service Pool/S a Natural Bathing Ar <br /> to <br /> Nunber o!Pool <br /> slSPas at Facility <br /> SITE MMGATIOH PROGRAM {2900} <br /> > UST/CAP Local Hoz Waste Haz Mat Pi aline <br /> Environmental Assessment <br /> 1 cal EPA•RWOCS I Ce1 EPA-DTSC I US-EPA <br /> Other Lead Agency Site I Wolof o"eery sit. I other <br /> 1 NPL Site <br /> X SOLID WASTE PROGRAM {4400} <br /> k A Canner Waste Site Units- 1 <br /> Landfill Transfer Station ' <br /> Number at Units <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Number of Unit+ <br /> Waste Tire Facili Procese/Rec cle Facility <br /> num eters �20 curd <br /> r VECTOR CONTROL PROGRAM {4000 <br /> Mnxlmlrm Number of 61+ds ijO Kennel <br /> Poultry Farm <br /> Emergency <br /> Night <br /> NodriceEon for this FACtuTY andlor PROGRAM <br /> Dey <br /> CONTACT PERSON: <br /> `Sy ,`fiber or utllt� EPA1[I K <br /> ,'t Defigrtatad ErhpltryYe PiOglal Vitsrit d' t:.trtr6ttt gtbtu►� N } <br /> L <br /> Receive ale eY @He_ y ale OOOUn Pg Oa <br /> eu <br /> ate <br />