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r <br /> SJ COUNTY PHS-ENVIRONMENTAL HEALTIi DIV ISI MASTERFILE R INFORMATION FORM {EH 00 59(Revised 6/941} <br /> I.( New EH Program/Existing Facility F New EH Program/New Facility Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY oZ 3J .�a ✓Z A <br /> FACILITY ID # 00164A RECORD ID # <br /> Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> DAIRY PROGRAM {2000} o 3.3 <br /> Grad.A Only Grade P Dairy Milk Di.pons.r Number of Containers in Multi-Head Unit <br /> FOOD PROGRAM {1600} <br /> 1 Sating capacity I Sgnnre Footage Produce Stand Ice Plant <br /> Restaurant 1 1 <br /> Commissary Vendin Machines <br /> 1 Dry Storage only 1 with Food Preparation Number of Units <br /> 1 Square Footage 1 with Meet Market only 1 with Food Preparation I Dry Goods only <br /> Retail Market <br /> Make I Vehicle Type I Color Registration # i License# <br /> Food Vehicle 1 1 <br /> Make 1 V.hicle Type 1 Color i Registration # i Ucense# <br /> Mobile Food Unit 1 1 I <br /> �en,,pma,ry Food Facility �[Sp,,,ial,Event <br /> atoferation from to ateof peration from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 Tons genorated per your <br /> Hazardous Waste Generator �y <br /> Categorically authorized C/1 Categorically Exempt fit Permit by Rule <br /> Tiered Permit Facility 1 ALJ V <br /> HOUSING PROGRAM {2400) EMPLOYEE HOUSING {2700} <br /> I Number or Units Numbor of Enploye.s Dairy Employee Housing <br /> Hotel/Motel <br /> Approximote Dates of Occupancy <br /> Jail or Exempt Institution 1O <br /> LIQUID WASTE PROGRAM (4200) <br /> 1 Registration # I License # I capacity I Vehicle# <br /> Pum er Vehicle <br /> I <br /> I <br /> Pumper Yard Packa a Treatment Plant Chemical Toilets Number of Units <br /> MEDICAL WASTE PROGRAM {4500} <br /> L <br /> Care Acute Care Skilled Nursin Lar a Generator <br /> enerator Transfer Station Limited Hauler Veterinary Clinic <br /> 11 -60 genrators >60 generators <br /> 2-10 generators I In Storage Facility <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool <br /> Spa Out of Service Pool/Spa Natural Bathing Area <br /> Number of Pools/Spas at Facility Pool/Spa ID# <br /> SITE MITIGATION PROGRAM {2900) <br /> Environmental Assessment UST/CAP Local Haz Waste Z Mat Pi aline <br /> I Cal EPA-RWQCB I Cal EPA-DTSC I US-EPA <br /> Other Lead Agency Site <br /> I NPL Site 1 Water Quality Site 1 Other <br /> SOLID WASTE PROGRAM {4400) <br /> Landfill Transfer Station A /Can ery Waste Site <br /> Number of Units <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Number of Units <br /> Waste Tire Facility Process/Recycle Facility Dunt sters >20 cu yd <br /> VECTOR CONTROL PROGRAM {4000} <br /> Poultry FarmMaximum Number or Birds Kennel <br /> Emergency Notification for this FACILITY and/or PROGRAM Day Night <br /> CONTACT PERSON: <br /> Ena;dyee# Program dement#22 Current Status Number of Units I n O� <br /> Dat. Reviewed yate coountmg Office ats ut C OF ate nit to ate <br />