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SJ COUNTV PHS-ENVIRONMENTAL HEALTH DIVISION MASTEAFILE RECORD INFORMATION FORM{EH 0�0-/SSIRevl.ed 6/941} <br /> New EH Program/Existing Facility New EH Program/New Facility ate —ClJ — -[ S <br /> SHADED $ECTlONS FOR LOCAL USE ONLY JJ <br /> ACILiTY.ID At , E2 RECORD ID # `� <br /> Planes Mark the Appropriate Description and Specify 8=e and/or Number of Unite where applicable: <br /> DAIRY PROGRAM (2000} <br /> Orade A Oeiry Grade B Dalry Milk 01......r Number of Containers In Muid4leed tint <br /> FOOD PROGRAM {7600} <br /> Restaurant I Setting Cepeolty I Sauare porous, Produce Stand Ice Plant <br /> Commissar 1 Dry Stones only 1 with Food Pr.peretlon Vendin Machines Nunber of unit. <br /> ,tail Market <br /> I aeoss Foot... I with Meet Market only I with Food Preparation I Dry Good.only <br /> Make I Vehicle Type 1 Color I Registration i I U.enn 9 <br /> Food Vehicle 1 I 1 I l <br /> 1 <br /> Mobile Food Unit Make I VeNcle Type 1 Color I Registration I I Moen..A <br /> I I I 1 I <br /> Temporary Food Facility Special Event <br /> Dates of Operation ham to Date.of Operation from to <br /> HAZARDOUS WASTE PROGRAM (2200} <br /> Hazardous Waste Generator I Tons aenarsted per year <br /> Tiered Permit Facilit Categorically authorized Categorically Exempt Permit by Ibis <br /> HOUSING PROGRAM (2400) EMPLOYEE HOUSING (2700) <br /> 1 Number of UNN Nunber of Employe.t DMry Employee Hou.ina <br /> HOtellMotel <br /> Approxlmete net..of Oo.op.noy <br /> Jail or Exempt Institution m <br /> LIQUID WASTE PROGRAM (4200} <br /> Pumper Vehicle I neaistretion I 1 U.."..A 1 C.p.oity 1 vehicle R <br /> l <br /> Pumper Yard ant Number of Units Package Treatment PlChemical Toilets 1 <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Lotus Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facilityi 2-10 gen.r.tar. i 11-so gen.rrmr. i >so a•n.remr. <br /> RECREATIONAL HEALTH PROGRAM (3600} <br /> Pool Spa Out Of Service Pool/spa 1 Natural Bathina Area <br /> Nunber of Pools/Spee at Facility PoolISPs ID A <br /> _SFrr MmGATION PROGRAM (2900} <br /> Grim,. <br /> Environmental Assessment UST/CAP �/ QG�1U Local Hez Waste Haz Mat Pipeline <br /> Other Lead Agency Site I CM EPA-RWOCB bfAOC)5t Cel EPA-OT6C I us EPA <br /> I NPL Site 1 water Quality Site I Otber <br /> SOLID WASTE PROGRAM {4400} WiU5 M + hl <br /> Landfill Transfer Station A Canner Waste Ske <br /> CIA Landfill Sit' <br /> Sludge/Ash Site Compost Facility Refuse Vehicles Number or Unite <br /> Waste Tire Facilit Process/Rec cle Facility Dom oters >20 cu yd N.."bar or m,it. <br /> VECTOR CONTROL PROGRAM (4000) <br /> Poultry Farm M..Imwn Number of Birds Kennel <br /> Emerg.my Noaflaetiun for this FACIUTY and/or PROGRAM Dry Night <br /> CONTACT PERSON: 004 ) 21 O g ( ) <br /> Deeip�u�teA Dn Playas A n J n } Pro9mm De ne ii A .i ,�-J Current Sows Numbs,of Uuh, EPA ID/ <br /> 1 <br /> .o.Iva <br /> by m. o y Um, ,came ole Unit cjaui, Dole Unit Stull Drta <br />