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SJ COUNTY PHS -ENVIRONMENTAL HEALTH D 1!" N MASTERFILE R ^ORD INFORMATION FORM(EH 00 59(Raviesd 61941) <br /> r <br /> lJLW New EH ProgramlNew Facility Date — 77 New EH ProgremlF�tieting Facility 7—S- 77 <br /> i <br /> SHADED SECT/ONS FOR LOCAL USE ONLY ,rte {� <br /> FACILITY ID # RECORD ID # a t/ 0 <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} o� <br /> Glade A Dairy - Grwde B Dairy Milk Dispernar Number of containers in Muld-Need Unit <br /> FOOD PROGRAM {1 6001 <br /> I Seating Can" <br /> citp I Square Footage Produce Stand lce Plant <br /> ' Restaurant <br /> 1 Dry Storage Only I with Food Prenamtioa Number of Units <br /> Commissar Vendin Machines <br /> I $rpmrn FOotaoe I with Meat Markat only I with Food Praparedon I DN Goods oniy <br /> Retail Market <br /> I Make I Vdlcte Typa I Color I Registrmlon S 1 Ueense!t i <br /> Food Vehicle I 1 1 I 1 <br /> 1 Make I Vehicle Type r Color 1 ReOistmtion.t I Ucensa X f <br /> Mobile Food Unit <br /> i <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Datsa of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tons generated per year <br /> Hazardous Waste Generator rJ <br /> II categorically Exempt 1 Permit by Rule t <br /> 1 Categorically authorized II <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I <br /> I Number of Units Number of E,nployeea Dairy Employee Housing <br /> Hotel/Motel <br /> Approximate Dates of Occupancy <br /> Jailor Exempt Institution tO <br /> LIQUID WASTE PROGRAM {4200} <br /> i Registrndon M I Ucanse A 1 Capacity I Veh cle j <br /> Pumper Vehicle I I i <br /> � Ntmbsr of Units <br /> Pumper Yard I Packs a Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> i <br /> 2-70 generators t t-60 generators I >60 generators <br /> 1 <br /> Common Storage-Facility I 1 1 <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Spa Out of Service Pocf/S a Natural Bathing Area <br /> Number of PoolslSP"at Facility Pool/Spa 10 <br /> SITE MmGAT1ON PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> I Cel EPA-RW QC8 1 Cd EPA-OTSC I US-FPA <br /> Other Lead Agency Site <br /> I NPL Site I Water Quality Site I Other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Ag/Cannery Waste Site I <br /> Number of Units II <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Number of UnitsI <br /> Waste Tire FaEE!y Process/Rec cle Facility Dum sters >20 cu yd 1 <br /> VECTOR CONTROL PROGRAM {4000} <br /> Maximum Nranber of Birds <br /> Poultry Farm Kennel 1i <br /> Emergency Nntifl—tion for this FACiUTY mel/or PROGRAM Day Night <br /> CONTACT PERSON; I I t I <br /> ER�.q—d <br /> ee fr Program Bement#,2 ' '"7�. Current Stnttn Number of Units AID# Zz <br /> Onto Ravtewad by to ccounring Ultme ate nit Clark ate nit ts ate <br />