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' SJ COUNT�NVIRONMENTAL HEALTH VISION <br /> MAST E RECORD INFORMATION FORM(EH 9) <br /> NewEH Program/Existing Facility New EH Program/New Facility . ) <br /> Facility ID#: ( ?0t / <br /> I kProgram Record ID#: -J 1150�(�/j�,('(/'��J�� <br /> FOOD PROGRAM(1600) -M4 O " <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) <br /> Hazardous Waste Generator Tons generated per year <br /> Tiered Permit Facility Conditionally authorized Conditionally Exempt Permit by rule <br /> - <br /> Tiered <br /> PROGRAM(2400) <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 number of birds Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> Tattooing '(4121) Body Piercing (4120) Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> Pumper Vehicle Registration# License# Capacity <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 I—60 generators >60 generators <br /> Einer encv Notification for this FACILITY and/or PROGRAM <br /> BUSINESS CONTACT PERSON: Da Phone: �Night Phone: <br /> PROGRAM ELEMENT# INSPPEC, OR# <br /> Permit fee: Permit Valid: to <br /> Food Handlers Course Check/Cash: <br /> Reviewed by Date <br /> Accounting Office — Date YJ Invoice# <br /> Rev. 0)4/09/99 <br />