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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVI MASTERFILE' ZD INFORMATION FORM{EH 00 59(11...1 61941) <br /> New EH Program/Elis[ing Faoilky New EH Progrpnl/New Facility Data <br /> SHADED SECTIONS FOR LOCAL USE ONLY ''� eZ"I <br /> FACILITY ID # 'S L 4RECORD ID # <br /> EEE] <br /> Please Mark the Appropriate Description and Specify Size end/or Number of Unita where applicable: <br /> _ DAIRY PROGRAM (2000) <br /> Grade A Dairy Grade B Dalry Milk Dispenser Number of Centel--'.in M.Wtl .ad Unit <br /> FOOD PROGRAM {1600) <br /> I Seed.,Capacity I square Footer. produce Stand Ice Plant <br /> ' Restaurant <br /> I with Food Preparation Number of Units <br /> 1 Due srorage emir VendingMachines <br /> Commissar <br /> I a.rrar.Feet.,. I with Meet Marker rd, I with Food Preparation I Dry Goode only <br /> Retail Market <br /> I Make I Vehicle Type I Cdor t Regbtrntlon! ; Ucema A <br /> Food Vehicle I I 1 I <br /> I Make I VaNcle Type I Color I Re,iend.n tl I Ur.n•e A <br /> Mobile Food Unit I I I I I <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates o1 0,.r.don from m <br /> HAZARDOUS WASTE PROGRAM {2200) <br /> 1 Tons generated per year <br /> Hazardous Waste Generator <br /> C.t.,.dedly amhof.ad Celegmdeally usngresw 3 I Permilby Rule <br /> Tiered Permit Facility <br /> HOUSING PROGRAM {2400) EMPLOYEE HOUSING {2700) <br /> I Number of Unita Nunber of Employe.+ U.1,Employee flossing <br /> Hotel Motel <br /> Approximate Dates of Occupancy <br /> Jail or Exempt Institution to <br /> DQUID WASTE PROGRAM {4200) <br /> I Regletrndon A I Uearoe! I Capacity I VaNcle J <br /> Pum er Vehicle <br /> Number of unit.Pum er Yard j Packs a Treatment Plant Chemical Toilets I <br /> MEDICAL WASTE PROGRAM {4500) <br /> Prima, Care Acute Care Skilled Nursing Generator <br /> Small Generator Transfer Station Limited Hauler Jinary Clinic <br /> Common StorageFacilit 2-1o, rauemre i 11 60 gBneram,• q7:- �50 enerator• <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Pool I Spa Out of Service Pool/Spa Natural Bathina Area <br /> Number of Pools/Spa$at Facility PoollSpe ID A <br /> SNE MmGAnoN PROGRAM (2900) <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site I Cd EPA-RwocB I Cal EPA-DTSC I USEPA <br /> I NPL Site I wets,Quality Sim I Other <br /> SOLID WASTE PROGRAM {4400) <br /> Landfill Transfer Station Ag/Cannery Ag/CanneryWaste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of Units <br /> Waste Tire Facilit Process/Rec cls Facility 20 cu yd Nunber or Unit, <br /> VECTOR CONTROL PROGRAM {4000) <br /> Poulby Ferro Mexlmum Number of Birds Kennel <br /> Emergency Nodfrcation for lMe FACULTY ad/or MOQRIIM Day Night <br /> CONTACT PERSON: 1"-A q,rk G {�✓1� (2.C)q ) q qq-.SSS 0 1 1 <br /> E <br /> yee A program Bemoan A �q 0 5 Current status Number or Unit. <br /> Data .yi.we y Data G•4 cOounhn, I.e Data <br /> ni,Clark ate pt le J at.�1 <br />