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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIV MASTER-1 E D INFORMATION FORM(EH 00 591Revlsed 6/94)} <br /> New EH Program/Existing Facility I New EH Program/New Facility I e <br /> SHADED SECTIONS FOR LOCAL USE ONLY JsJ <br /> FACILITYID ;<# © RECORD ID off. ' <br /> Please Mark the Appropriate Description and Sppeyo�ify Size and/or Number of Units where applwabl <br /> DAIRY PROGRAM {2000} <br /> Grade A Dairy Grade B Dairy Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD PROGRAM {1 6001 <br /> I Seating Capacity I Square Footage <br />' Restaurant Produce and Ice Plant <br /> I Dry Storage only I with Food Preparation Number of UnitsVendin Machines <br /> Commissar <br /> 1 Square Footage I with Most Market only I with Food Preparation I Dry Goods only <br /> Retail Market <br /> Make I Vehicle Type I Color 1 Registration# I Ucense# <br /> Food Vehicle 1 I I I I <br /> 1 Make I Vehicle Type ; Color ; Registration# i Ucense# <br /> _71 <br /> Mobile Food Unit I <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200) <br /> LFHad-us Waste Generator 1 Tans generated per year <br /> Categorically authorized Categorically Exempt / Permit by Rule <br /> rmit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700) <br /> I Number of Units Number of Employees Dalry Employee Housing <br /> Hotel/Motel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> 1 Registration# 1 License# I Capacity I Vehicle# <br /> Punt er Vehicle <br /> Pumper Yard Package Treatment Plant Chemical Toilets I Number of Units <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Larne Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 2-10 generators 11-60 generators >60 generators <br /> Common Storage Facility <br /> RECREATIONAL HEALTH PROGRAM {36001 <br /> Pool S a Out of Service Pool/Spa Natural Bathin Area <br /> Number of Pools/Spas at Facility Pool/Spa ID# <br /> SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pi eline <br /> Other Lead Agency Site I Cal EPA-RWQCB I Call EPA-DTSC I US-EPA <br /> I NPL Site 1 Water Quality Site 1 Other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Aq/Cannery A /CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of Units <br /> Waste Tire Facility Process/Recycle FacilityDum sters >20 cu yd Number of Units <br /> VECTOR CONTROL PROGRAM {4000) <br /> Maximum Number of Birds <br /> Poultry Fane Kennel <br /> Emergency Notification for this FACIUTY and/or PROGRAM Day / Night <br /> CONTACT PERSON: <br /> EnaledEmployee# Program semorri 8 /\!►' Currant S tus t Number of Unita EPA 10 i1fir t4 ate. evewe <br /> g; ate 000un ng. ce ate tat a et�f t to ste.> <br />