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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DTVI' MASTERFILE D INFORMATION FORM(EH 00 59(Rovised 6194)) <br /> New Ell Program/Existing Facility IF New Elf Program/New Facility Date 7 E:= <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> EFACILITY ID # RECORD C ORD ID # <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} <br /> Grad.A D.,,y Grnd9 r Doily Milk Dir;p.­., N,,,,b.r of Containers In Will Head Unit <br /> FOOD PROGRAM {1600} <br /> Restaurant 1 Snating CapacitySquat.F­tnqo• IP—,.duce Stand —11 lee Plant <br /> 1 Dry Storage only Food P'.P.'oti.n Nuriba,of Units <br /> Commissary I Fending Machines <br /> 1 Square Footage i with KA.ot Mnrk.t only I with Food Prepnratl mr I Dry Goods only <br /> Retail Market <br /> hicle Make V.1,1.1.Typo Color Registration Ll..,,.o <br /> Food VeM.ko I vehicle Type I Col., l nriglilt'.ticin # I U.rinvie# <br /> MGbile God Unit <br /> Temporary Food Facility Special Event <br /> Drims of Operation from to Dotes of Operation frOITI to <br /> HAZARDOUS WASTE PROGRAM 122001 <br /> Hazardous Waste Generator 1 Tons grinernted per year <br /> V <br /> Tier categorically authorized categorically Exempt Permit by Bills <br /> .rd Permit Facility <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> i Number of Units Number of Enployeas Dairy Enployea Housing <br /> Hotel/Motel <br /> Approldinote Dates of Occupancy <br /> Jail or Exempt Institution I to <br /> LIQUID WASTE PROGRAM 14200) <br /> Pumper Vehicle 1 R.gist'riti.n # # 1 Capacity # <br /> Number of Units <br /> Pumper Yard IPacka a Treament Plant Chemical Toilets <br /> MEDICAL WASTE PROGRAM 145001 <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> y 2 10 generators 11 -GOU......tots >60 <br /> Common Storage Facilit <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool1 Spa Out of Service Pool/Spa Natural Bathing Area <br /> Number of Pools/Spas at Facility Pool/Spa ID# <br /> SITE MITIGATION PROGRAM 129001 <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> C.1 EPA-RWQCB I Cnl EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> 1 NPL Sit. 1 Wroor Ounlity Site 1 Other <br /> SOLID WASTE PROGRAM 144001 <br /> Landfill Transfer Station Aq/CannerV Waste Site <br /> Number of Units <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Number of Unit. <br /> Waste Tire Facility Process/Recycle Facility _PELnpsters >20 cu yd <br /> VECTOR CONTROL PROGRAM {4000} <br /> Maximum Nto"bor of Birds <br /> Poultry Farm Kennel <br /> Emergency Notification for this FACIUTY aridlor PROGRAM Day Night <br /> �'T__� -,3 <br /> CONTACT PERSON: Q-"r,, ) (—/ <br /> Designated Employee# Program dement# Current_ tatos Worib.,of UnIl. <br /> EPA ID <br /> Rocoivad by Onto moviewrict oy Date Acuotoiting Office Data nit er ate 1lilt to onto <br />