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SJ COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> IV'CTERFILE RECORD INFORMATION FORM (FH 00 69) <br /> New EH�/Prognj xisting Facility New Program/New Facility <br /> Facility ID#: � 8S /0 � Program Record ID#: Sy ggq 9 <br /> FOOD PROGRAM(1600) <br /> Restaurant -- Seating Capacity Square Footage Produce Stand I ce Plant <br /> Commissionary Dry storage only with Food Preparation Vending Machines Numbers of Unit <br /> Retail Market Square footage _ w ith 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_ i <br /> HOUSING PROGRAM(2400) <br /> Hotel/Motel _- al or Exempt Institution Number of Units <br /> SITE MITIGATION (2900) / (� / ��/(OLeq-fT C��- <br /> R R4-F�A#�rl�-I1Erk ��� <br /> Pool Spa Out of Service Pool/Spa N atural Bathing Area Number of Pools/Spas at Facility <br /> VECTOR CONTROL PROGRAM(4000) <br /> Poultry Farm Maximum number of birds K ennel <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/Canner;Waste Site <br /> CIA Landfill Site Sludge/Ash Site Compost Facility R efuse 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 V eterinary Clinic <br /> Common Storage Facility 2 — 10 generators 1 I —60 generators > 60 generators <br /> Emergencv Notification for this FACILITY and/or PROGRAM <br /> BUSINESS CONTACT PERSON: Dav Phone: Night Phone: <br /> PROGRAM ELEMENT# -Z q � INSPECTOR# <br /> Permit fee: Permit Valid: to <br /> Food Handlers Course Check/Cash: <br /> C <br /> Reviewed by -�! ate <br /> Accounting Of tfce Date Invoice <br /> Rev. 02/01/99 <br />