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1 <br /> SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVISI MASTERFILE RE INFORMATION FORM 9H 00 591Revised 6/941) <br /> Net!EH Program/Existing Facility New EH Program/New Facility Oate <br /> SHADED SECT/ONS FOR LOCAL USE ONLY /�� <br /> FACILITY �D �# � i:' .. RECORD ID # " <br /> Please Mark the Appropriate Description end SpecHy Size endlor Number of Units where applicable. <br /> DAIRY PROGRAM {2000} aal3 - t5PO8 _ ? <br /> Grade A Dairy Grade B Dairy Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD PROGRAM {1 6001 <br /> I <br /> Restaurant Seating Capacity I Square Footage Produce and Ice Plant <br /> ' <br /> 1 Dry Storage only 1 with Food Preparation Number of Units <br /> CommissarVendingMachines <br /> 1 Sq( to FootageI with Meat Market only I with Food Preparation I Dry Goods only <br /> Retail Market <br /> Make ; Vehicle Type Color Registration# License# <br /> Food Vehicle 1 <br /> I Make 1 Vehicle Type I Color Registration# ' License# <br /> Mobile Food Unit I I I <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> HI rens generated per year <br /> Hazardous Waste Generator <br /> Tiered Permit Facility <br /> Categorically authorized Categorically Exempt Permit by Rule <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Unfts Number of Employees Dairy Employee Housing <br /> Hotel/Motel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> I Registration# I License# 1 Capacity 1 Vehicle# <br /> Pum er Vehicle <br /> Number of Units <br /> Pumper Yard Package Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursinq Lar a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility i 2-to generators 11-60 generators >50 generators <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Spa Out of Service Pool/Spa Natural Bathina Area <br /> Number of Poolsispas at Facility Pool/Spa ID# <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP (Local Haz Waste Haz Mat Pipeline <br /> 1 Cal EPA-RWQCB I Cel EPA-DTSC 1 US-EPA <br /> Other Lead Agency Site I 1 <br /> 1 NPL Site 1 Water Quality Site 1 Other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station An/Cannery An/CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of Units <br /> Waste Tire Facility Process/Recycle Facility Duro sters >20 cu yd Number of Units <br /> VECTOR CONTROL PROGRAM {4000} <br /> Maximum Number of Birds Kennel <br /> Lultry Farm <br /> Emergency Notification for this FACILITY and/or PROGRAM Day Night <br /> CONTACT PERSON: <br /> Designated Employee# Program 8em6 Cwierrt Staub: Number of Uhltr <br /> L/p <br /> _.:. <br /> ecewe y Dateuntmo.. 09 >. eta Unit Clark,,: f; eta t to <br />