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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DIVISION ANk MASTERFILE RECORJWORMATION FORM EH 009(Revised 8/94)) <br /> it New EH Program/Existing Facility ew EH Program/New Facility aye <br /> SHADED SECT/ONS FOR LOCAL USE ONLY <br /> FACILITY:ID # C :f} RECORt7 ID# > ` 0 <br /> DAIRY PROGRAM {ZOOO} Please Mark the Appropriate Description and Specify Size and/or Number of Units where applicable: <br /> Grade A Dairy Grade B Dairy Milk Dispenser Number of Containers in Multi-Head Unit <br /> FOOD PROGRAM {1600} <br /> Restaurant I Seating Capacity I square Footage Produce Stand Ice Plant <br /> I Dry Storage only 1 with Food Preparadon Number of Unita <br /> Commissar Van in Machines <br /> I Square Footage I with Meat Market only I with Food Preparation I Dry Goods only <br /> Retail Market <br /> Make I Vehicle Type I Color I Registration# I Ucense# <br /> Food Vehicle I I I I I <br /> Mobile Food Unit <br /> Make I Vehicle Type I Color I Registration# I Ucense# <br /> I I I I 1 <br /> Temporary Food Facility Special Event <br /> Dates of Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> .......................... -.............._....._.. <br /> ........................................................ <br /> I Tons generated per year <br /> Hazardous Waste Generator <br /> Tiered Permit Faclity Categorically authorized Categorically Exempt Permit by Rule <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING {2700} <br /> I Number of Units Number of Employees Dairy Employee Housing <br /> Hotel/Motel <br /> of Occupancy <br /> Approximate Dates <br /> Jail or Exempt Institution to <br /> LIQUID WASTE PROGRAM {4200} <br /> Pumper Vehicle I Registration# I Ucense# I Capacity I Vehicle# <br /> Pumper Yard =r Package Treatment Plant Chemical Toilets i Number of Unite <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Lar a Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility j 2-10 generators 11-60 generators >60 generators <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> Pool <br /> Spa Out of Service Pool/Spa Natural Bathing Area <br /> Number of Poois/Spas at Facility PoclfSpe 10# -? <br /> SITE MmGAnON PROGRAM {2900} <br /> Environmental Assessment UST/CAP Local Haz Waste Haz Mat Pipeline <br /> Other Lead Agency Site I Cd EPA-RWQCB I Cel EPA-DTSC I US-EPA <br /> I NPL Site I Water Quality Site I <br /> SOLID WASTE PROGRAM {4400} RECEIVED <br /> ............... <br /> Landfill Transfer Station A /Canner Waste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of Ursa <br /> '`� N sof Urrb <br /> Waste Tire Facili Process/Recycle FacilityDum ste <br /> VECTOR CONTROL PROGRAM {4000} ENVIRONMENTAL HEALTH DIVISION <br /> Poultry Farm Maximum Number of Birds 11 13 g / 4aKennel (/ <br /> Emergency Notification for this FACIUTY and/or PROGRAM y Night <br /> CONTACT PERSON: <br /> Designated Employee# Program_6emerit# � Current Statute Number of Unca EPA JD#I <br /> Receive by ate wsw r9 ate_, counting oe. ate f eta nt to ate <br />