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SJ COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> 1 • MA FILE RECORD INFORMATION FORM ( 69) <br /> New EH Program/E mg Facility New EH gr ew Facility <br /> Facility ID#: Program Record ID <br /> FOOD PROGRAM(1600) <br /> Restaurant -- Seating Capacity Square Footage Produce Stand Ice Plant <br /> Commissionary Dry storage only with Food Preparation V ending 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 /> 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 /> R ROGRAM(4000) PAYMENT <br /> Poultry Fane �p Maximum number of birds � i/�OD Kennel st+ '° ° <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) MAR 18 1999 <br /> Tattooing (4121) Body Piercing (4120) Permanent Cosmetics(4122) <br /> 4A'-t JUiilli 1N'(A4140`iY <br /> PUELIt ,iS;AUH�kki`ACV--. <br /> LIQUID WASTE PROGRAM(4200) ENVIRONMEN t Pd tr DIVISION <br /> Pumper Vehicle Registration# License# Capacity �ehicre# <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 D umpsters>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 11 –60 generators > 60 generators <br /> Emergency Notification for this FACILITY and/or PROGRAM T -?--3 W :z 0 3� <br /> BUSINESS CONTACT PERSON: �O Day Phone: / 115 / Night Phone: <br /> PROG ELEMEN # 4 (40 INSPECTOR# <br /> OCA <br /> Permit ee: ermit Valid: .3 /o' 9 to 1,2131 Z 12 <br /> Food ourse Chec Cash: 31,1?/ /l ol <br /> Reviewed by Date N-7 <br /> Accounting Office Date g Invoice# <br /> Rev.02/01/99 <br />