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...,,;r <br /> SJ COUNTY PHS-ENVIRONMENTAL HEALT N MASTERFIL 'ORD INFORMATION FORM(EH 00 59tRe.ni di 6/94)} <br /> New Efrf' rogram/Existing Facility ! New EH PrograntiNew Facility Date <br /> SHADED SECT/ONS FOR LOCAL USE ONL <br /> �Y <br /> y C� <br /> FACILITY ID # ( ' C/ RECORD ID # �0 <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} <br /> Grade A Dairy Grade B Dairy Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD PROGRAM {1600} <br /> I Seating Capacity I square Footage Produce Stand Ice Plant <br /> Restaurant <br /> 1 Dry Smraq.only 1 with Fnod P-P.ration Number of Vmits <br /> Commissar Vedincl Machines <br /> I Sramre Fantaoe I with Ment Market ualv I with F—d Preoaredon 1 Dry Goods only <br /> Retail Market <br /> Food Vehicle MA. ; vehicle Type I Color i Registration X ; ucen..X <br /> Food Unit <br /> Make ; vehicle Type ; Color ; Registration X ; Ucenss X <br /> Mobile 1 <br /> Temporary Food Facility Special Event �.�( Q•Q. j <br /> Dates of Operation from to Dates of Operation frau <br /> LQA <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tons generated per year - <br /> EHdous Waste Generator <br /> Categorically authorized Categorically Exempt Permit by Rule <br /> Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> 1 Number of Units Number of Employees Dairy Employes Housing <br /> Hotel/Motel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> t Registration X t Ucense X I Caoncity 1 Vehicle X <br /> Pumper Vehicle <br /> Number of Unita <br /> Pumper Yard FP—cka(e Treatment Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM {4500} <br /> i <br /> Primer Care I Acute Care Skilled NursingLarge Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility j 2.10 generators I I -60 generators >60 generator. !' <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> LErp---011— <br /> SITE <br /> S a Out of Service Pool/S a Natural Bathin Ar a <br /> f PoolslSpas at Facility Pod/Spa 1D XMITIGATION PROGRAM {2900} <br /> Environmental Assessment USTICAP Local Haz Waste Haz Mat Pipeline 1. <br /> Other Lead Agency Site I Cal EPA•RWQCB 1 Cal EPA-DTSC I US-EPA <br /> I NPL Site 1 Water Quality Site 1 Other j <br /> SOLID WASTE PROGRAM {4400} <br /> i! <br /> Landfill Transfer Station A /Canner Waste Site I! <br /> Number of Urns <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 sters >20 cu yd 1 <br /> VECTOR CONTROL PROGRAM {4000} <br /> Poultry Farm Maximum Nunb.r of Birds �) <br /> Kenna! <br /> Energency Notification for this FACILITY nndlor PROGRAM Oayf jl(r• '1 ) Q� Night p� �j <br /> CONTACT PERSON: �c�01 a J 3 p ',RIF 105 <br /> Designated Employee X V I Program Element XCurrert�Statin Number of Units i EPr�.I <br /> ererved by Date Revwwed by ate <br /> Accounting Office as ttit C ark / ate `tat to ate <br /> is <br />