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SJ COUNTY PHS-ENVIRONMENTAL HEALTH DNISIOIles/ lliiiiloe MASTERFILE RE MATION FORM{EH 00 59tRevised 8/94)) <br /> New EH PtogramlExisting Facility New EH Program/New Facility Date <br /> SHADED SECTIONS FOR LOCAL USE ONLY <br /> FACIIJtY XD.#.. } <br /> ECRL) D # <br /> Please Mark the Appropriate Description and Specify Size andlor Number of Unite where applicable: <br /> DAIRY PROGRAM {2000} <br /> Grade A Dairy Grade a Dairy Milk Dispense Number of Containers In Multiaisad Unit <br /> FOOD PROGRAM (1000) <br /> I Seating Capacity I square Footage Produce Stand Ice-Plant <br /> Restaurant <br /> I Dry Storage Only I with Food Preperadon Number of Units <br /> Commissar Vendin Machines <br /> I with Meet Market Only I with Food Preparation I Dry Goods only <br /> I Square Footage Y <br /> Retail Market <br /> Make Vehicle Type I Color I Reglstradon I i Llosnw# <br /> Food Vehicle i 1 <br /> I Make Vehicle Type Color Registration# i License 0 <br /> =M-bll. 00d Unit <br /> Temporary Food Facility Special Event <br /> Deter Or Operation from to Dates of Operation from to <br /> HAZARDOUS WASTE PROGRAM {2200} <br /> 1 <br /> Hazardous Waste Generator Tons genarated per year <br /> 1 <br /> Categorically authorized : Categorically Exempt Permit by Rule <br /> Tiered Permit Facili I <br /> HOUSING PROGRAM {2400} EMPLOYEE HOUSING (2700) <br /> 1 Number of Units Number of Employees Dairy Employes Housing <br /> EJ.I.rME.empl <br /> tel <br /> Approximate Dates of occupancy <br /> Institution to <br /> Liam WASTE PROGRAM {42(0} <br /> 1 Registration 9 1 Uoens■9 1 Capacity 1 Vehicle#Pum err Vehicle <br /> Pum err Yard Packer a Treatment Plant Chemical Toilets a Number of Units <br /> MEDICAL WASTE PROGRAM {4500} <br /> Primary Care Acute Care Skilled Nursing Lar a Generator <br /> Small Generator El Transfer Station Limited Hauler -7 Veterinary Clinic <br /> 1 <br /> Common Storage Facility2-10 genereton; 1 11-So generators >60 generators <br /> I <br /> RECREATIONAL HEALTH PROGRAM {3600} <br /> pool <br /> Spa Out of Service Pool S e Natural Bathin Area <br /> Ntmber of <br /> Poole/Spot at Facility 119P6 IDak <br /> SITE MITIGATION PROGRAM {2900} •1 <br /> Environmental Assessment USTICAP Local Haz Waste Haz Mat-Pipeline <br /> Other Lead Agency Site 1 Cal EPA-Rwoca I Cal EPA-DTSC I US-EPA <br /> 1 NPL Site 1 Water Quality Site I Other <br /> SOLID WASTE PROGRAM {4400} <br /> Landfill Transfer Station Ag/Cannery Waste Site <br /> CIA Landfill Site SludgelAsh Site Compost Facility Refuse Vehicles Number of Unlfs <br /> Waste Tire Facility Process/Recycle Facility Rum stere >20 cu d Number of Units <br /> VECTOR CONTROL PROGRAM {4000) <br /> Poultry Farm Maximum Number of suds Kennel <br /> Emergency Notifioatlon for this FACILITY and/or PROGRAM Day Night <br /> CONTACT PERSON: I 1 ( 1 <br /> Il<,eipriatbd E'irYploys�tF' `Prtipretn Bettrtltt+f .. ,' Curr�ttt Jitattri',: IVtirttb►r;'ofIlktlt! F.PAJi3#' <br /> O ' <br /> Flocelvel by Date Reviewed D1t9:,- acpun ng Q ffk;Q:: eb te 4 C tM - ate <br />