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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVISICS MASTERFILE RE4b INFORMATION FORM(EH 00 59(Revised 8/94)} <br /> New EH Program/Existing Facility New EH Progra (New Facility FY'Date F f P' 97 <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> .:............ AC LtTY Cid: ............. .............:.. <. :> ::• :.>'.:: <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where'appliieable:. <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 /> 1 Seating Capacity I Square Footage <br /> Restaurant Produce Stand Ice Plant <br /> I <br /> Commissar Vendin Machines <br /> Dry Storage only I with Food Preparation Number of Units <br /> 1 Square Footage1 with Meat Market only I with Food Preparation I Dry Goods only <br /> etail Market <br /> Make I Vehicle Type 1 Color I Registration* 1 Ucense 1 <br /> Food Vehicle 1 I I I I <br /> 1 Make 1 Vehicle Type I Color I Registration# I Uoense#r <br /> Mobile Food Unit I I I I 1 <br /> ETen,p�orery Food Facility Special Event <br /> ration from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> Tons generated per year <br /> +':•"•.'S::•.i$iv?<%''• <br /> g P Y <br /> E <br /> azardous Waste Generator <br /> iered Permit Facilityj Categorically authorized Categorically Exempt Palydt by Rule <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Units Fumba, Ernployees Dalry Etnployss FbtlNnq <br /> Hotel/Motelte Dates of Occupancy <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> Pumper Vehicle I Registration# I Ucanse;r I Capacity I Vehicle d# <br /> Pumper Yard —7:1Package Treatment Plant Chemical Toilets 1 Number of Units <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursina Large Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facilityj 2-10 generators 11 -60 generators >50 generators <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool Spa Out of Service o 1 ISpa Na ural Ba i Area'r <br /> Pool S e ID�R :::<:•.:'•i:'<•ii;.;•.;;•::;•i:•i::<•i:•is•i:•i:•i:<•:;:•i:.:.:•i:;<•i;:•iii::•i:•ii:;•;<•i:•i:•i:•i:•i:•i:•ii:<•i.'•:•ii:•i:.i:•:•i:•::•;:«:+':: 'i?:'';;?ti':<,; <br /> Number of PoolslS as at Facili L.P..:.... - <br /> SrnE MITIGATION PROGRAM {2900} PAYMENT <br /> Environmental Assessment UST/CAP Local Haz Waste R a aFpVwine <br /> Other Lead Agency Site I Cal EPA-RWGCB 1 Cel EPA.DTSC 1 u -E <br /> I NPL Site 1 Water Quality Site o. er <br /> SOLID WASTE PROGRAM {4400} SAN JOAQUIN COMEN <br /> UNTI <br /> R .......... .�.F.... <br /> Landfill Transfer Station ���Tl .:.::::::::::::.;>;:.;:>:;::•;;:•:::•;:%�>srs:�:::::>:��::>:�:�<>:�:>ii;:�:•r�:>.�::.:. <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Reftfse Vehicles Number of Units <br /> Number of Units <br /> Waste Tire Facilit Process/Recycle Facility ;;.:..::;:.,.;,::.,,:.: Dum sters >20 cu yd <br /> VECTOR CONTROL PROGRAM {4000} <br /> Poultry Farm Maximum Number of Birds - Kennel <br /> Emergency Notification for this FACWTY and/or PROGRAM Day Night <br /> CONTACT PERSON: e `(S 7-AL U poej) Y&I(P4, ( ZOg) P5 e-/T2 <br /> ... ..�::':::<.;:::::. ..:....::.::-:•:::•::.�:::::. >:;a:.:::::.:'ii••:�:ii:yi;•••i:•i,;.,y.,..;:�i iii:•r:•i:•,o . <br /> ,_. .:..:: •::::•:.�:.::::::'.: .; i ::4i;.;:.i:+:::.:.:+'i:: 'k:::i'::::: •.iii::::.::S:CJ:ii:::::: � ;:•Yo-i:ry:?;{:ii:4:<•:�:{n?:}i:•ii: .:Jiii::•::i:4:w:::rn•:r..}......... <br /> Ii9tl ii3fi:(iYl : :. :. :•:::::•.::pr.0.kafm; 191A$►If lY :.:,ir` :::::::I�/Mtil.Qf.4fNl ::::::.::•:::.::..:::..:::. 14. <.::.::::::.::.:...............:...:.:... <br /> td!M!...........N14Y .......... N. A.......................... <br /> :•ii;•iiii:iii::::::::.�:.�::::::::;::::.�:::::::.. ... i.:.. •.�::v:•i>:4' '��,. ":•.:�•.• •ii iLii:•ii:•:i4:<•ii:«<4ii�i'ii}::};;:.;:::::::::::::::::•::�:•:::::::•::i.:'.•ii'r'i4}iiiii:G: <br /> ................. <br /> Mp <br /> Ma <br /> . <br /> ti <br />