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SJ COU W� ENVIRONMENTAL HEALTIRDIVISION <br /> MAS ERFILE RECORD INFORMATION FORM (EH 00 69) <br /> New EH Program/Existing Facility New EH ProgrsmMew Facility <br /> Facility ID#: 0 `f�'2 ate Program Record ID#: 5/514L4 <br /> FOOD PROGRAM(1600) <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 ik 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 Number of Pools/Soas at Facility <br /> VECTOR CONTROL PROGRAM(4000) <br /> Poultry Farm Maximum number of birds Kcnncl <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 /> a en <br /> 4ommon <br /> Transfer Station Limited Hauler Veterinary CIinic <br /> Storage Facility 2—10 generators 11—60 generators >60 generators <br /> Emeraency Notification for this FACILITY and/or PROGRAM <br /> BUSINESS CONTACT PERSON: &yerr60J Wit; Day Phone: y�o� .31L�/ X . <br /> CNight Phone: <br /> PROGRAM ELEMENT# ��JZ-- INSPECTOR# <br /> Permit fee.--* <br /> ee:-*34 Permit Valid: q/11:5-/q q to �Z13!!C1 moi' <br /> Food Handlers Course (:CDheck/ ash: 1,59 -7-7 <br /> Reviewed by Date q `� <br /> Accounting Office LA Date R 1 Invoice# DC��7�GS <br /> Rev.04/09/99 <br />