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Si COUN P.- ENVIRONMENTAL HEALTI�IVISION <br /> MASTERFiLE RECORD INFORMATION FORM (Eh u0 69) <br /> New EH Program/Existing Facility New EH ProgramMew Facility <br /> Facility ID#: O D 3 6 9 / Program Record ID#: - - <br /> FOOD PROGRAM(1600) 02:-6 444 <br /> Restaurant -- Seating Capacity Square Footage Produce Stand Ice Plant <br /> Commissionary Dry storage only with Food Preparation Vending Machines Numbers of Unit _ <br /> Retail Market Square footage with Meat Market only Multiple Departments . Prepackaged Goods Only <br /> Mobile Food Facilities Make: Vehicle Type: Color. , <br /> Registration#: License#: Sticker# <br /> Mobile Food Prep Unit Make: Vehicle Type: Color: <br /> Registration #: License#: Sticker# <br /> Temporary Food Facility Dates of operation: from to <br /> Special Event Dates of Operation: from: to <br /> DAIRY PROGRAM (2000) (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 /> HAZARDOUS WASTE PROGRAM(2200) /4 (00 y�rscvy z�' 7�a- r✓ f _ �OoO <br /> ` ' �,9�°q?�D,� <br /> Hazardous Waste Generator Tons generated per year <br /> Tiered Permit Facility Conditionally authorized Conditionalalllyt Exempt Permit by rule <br /> HOUSING PROGRAM(24W) 'E- Rn e- A've.J /rt��GCGtr <br /> Hotel/Motel Jail or Exempt Institution Number of Units <br /> i SITE MITIGATION(2900) <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Pool Spa Out of Service Pool/Spa Natural Bathing Area Number of Pools/Spas at Facility <br /> VECTOR CONTROL PROGRAM(4000) <br /> Poultry Farm Maximum numberof birds Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> Tattooing (4121) Body Piercing (4120) Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> Pumper Vehicle Registration# License# Capacity Vehicle <br /> Pumper Yard Package Treatment Plant Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> Landfill Transfer Station Ag/Cannery Waste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility Refuse Vehicles Number of Units_ <br /> 'Waste Tire Facility Process/Recycle Facility Dumpsters>20 cu yd Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> Primary Care Acute Care Skilled Nursing large Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility 2— 10 generators I 1—60 generators >60 generators <br /> Emersencv Notification for this FACILITY and/or PROGRAM tet <br /> BUSINESS CONTACT PERSON: Bob " <br /> Day Phone: ?4)-7 74- - <br /> � ` fe- <br /> Night Phone: <br /> PROGRAM ELEMENT # 3 9 b INSPECTORlqg.S <br /> Permit fee: Permit Valid: m �Y <br /> Food Handlers Course Check/Cash: <br /> Reviewed by Date <br /> Accounting Office Date 7 Invoice it <br /> Rev.04/09/99 <br />