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IkIN 5. t <br /> SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVISI MASTERFILE RF TD INFORMATION FORM(EH 00 591R...le.d s/sAl} <br /> N EH P g /E ' t g F 'lily New EH Program/New Facility r Data <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> FACILITY <br /> 1D # OOS30 y RECORD ID # <br /> Please Mark the Appropriate Description and Specify Size end/or NUmbez of Unite where applicable: <br /> _ DAIRY PROGRAM {2000} <br /> Grade A Dniry Gmd t B they Milk DUp.m., Numbo of containers in M.16".ad Unit <br /> _FOOD PROGRAM {1600} <br /> I seating capacity I sgaa..Foote.. Produce Stand Ice Plant <br /> Restaurant <br /> I pry Storage only I with Food PrepareganNuob.r of UMu <br /> Commissar IrV.nding Machines <br /> I equate FooM.e I with Mee,Merkel oNy I with Food Prepwer— I Dry Good.oNY <br /> Retail Market <br /> I peak, 1 VaIJM.type 1 Co., I R.,leneeon ! LicenseFood Vehicle I 1 1 1 <br /> 1 M.ke Vehicle Type I Co., 1 R.,min,tio.! 1 U.....I <br /> Mobile Food Unit 1 1 I <br /> Temporary Food Facility Special Event <br /> Do,..of op.,etio. ho.. ro notes of onaragm, from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> I Tone generated per year <br /> Hazardous Waste Generator <br /> I CemgodeMly euthodzed categorically Fxwmpt Pa,ma by R,tls I <br /> Tiered Permit Facilit 1 <br /> _HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of UMu FFA, <br /> er of Dnploy... Dairy[ployes/bwing <br /> Hotel/Motelzimaa oat..of oppupenpy <br /> Jail ar Exempt Institution 11 <br /> to <br /> _ LIQUID WASTE PROGRAM {4200} <br /> I R.,harer.n P 1 U.h.e A I Capacity I VeNale <br /> Pumper Vehicle <br /> Number of Uelte <br /> Pumper Yard Package Treatment Plant Chemical Toilets <br /> _ MEDICAL WASTE PROGRAM {45500} <br /> Primary Care Acute Care Skilled NursingLarge Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> 1 2-10......tore 11 -so gent,wor. >So....tato.. <br /> Common Storage Facilit l <br /> _RECREATIONAL HEALTH PROGRAM [3600} <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area <br /> Nlanbe,of Poole/Spa.at Facility P..I/Sp.ID 0 <br /> _SITE MITIGATION PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> 1 Cel EPA-RWOCB 1 CM EPA-DTSCI USEPA <br /> Other Lead Agency Site <br /> 1 NPb Sit. I Wale,Guality Sita 1 OOmr <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Ag/Cannery Ag/CanneryWaste Site <br /> Nlmbsr of UNn <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles <br /> Number of Units <br /> Waste Tire Facility Process/Recycle Facility Dum stere >20 cu Yd <br /> _VECTOR CONTROL PROGRAM {4000} <br /> Meele,u,.Number 01 Blida Kennel <br /> Poultry Farm <br /> nergancy Noll.pndon for this FACILITY and/o,PROGRAM Do, Night <br /> D <br /> CONTACT PERSON_ ( ( , <br /> O.aignMed Employee> Pro,rmn Bement A,- ''7(�' Currant Stetoa Nunber of UMte EPA ID <br /> e by <br /> ate .VIewO Y ere G••C]0011111111. ICO el. til, 0. Vats ,.t b ate <br />