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SJ COUTV" ENVIRONMENTAL HEALTTT 'DIVISION <br />MAS .—,<I-fLE KEC;UKll 1NI-UKMA l IUN t'UKM (t-- J by) <br />New EH Program/Existing Facility New EH Program/New Facility <br />Facility ID#: 00 VP_ <br />Program Record ID#• :J off b <br />FOOD PROGRAM (1600) <br />Restaurant -- Seating Capacity � ua e 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 />HOUSING PROGRAM (2400) <br />Hotel/Motel Jail or Exempt Institution Number of Units <br />s SITE MITIGATION (2900) <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Pool Spa Out of Service Pool/Spa Natural Bathing Area dumber 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) <br />Pumper Vehicle Registration # <br />Pumper Yard Package Treatment Plant <br />License #_ <br />Chemical Toilets <br />Capacity Vehicle # <br />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) PAYMENT <br />Primary Care Acute Care Skilled Nursing Large Generator +.-11 frz <br />Small Generator Transfer Station Limited Hauler Veterinary Clinic ®A <br />Common Storage Facility 2 — 10 generators I 1 — 60 generators > 60 generators MAY 6+ 'jQQQ <br />Emer-encu Notification for this FACILITY and/or PROGRAM <br />BUSINESS CONTACT PERSON: <br />PROGRAM ELEMENT # <br />7 <br />SAN J0AC1J1N CUUN ry <br />PUSUC HEALTH SEpVICES <br />ENVI�1� <br />Day Phone: a <br />INSPECTOR # — M" e) <br />C,/L,,'s/3r /01)Permit fee: 2z0�_ Permit Valid: 5 �� I CI to <br />Food Handlers Course Che Cash: 385 S �aZ a D <br />Reviewed by w� �° Date <br />Accounting Office Date 5���4g Invoice #. <br />Rev. 04/09/99 <br />