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SJ COUN&ENVIRONMENTAL HEALTI-WIVISION <br /> ~ MAS LE RECORD INFORMATION FORM(ERM 69) <br /> Ne EH Program/Existing Facility New EH Program/New Facility <br /> Facility ID#• Program Record ID#• O <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#: 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//Spas at Fpgaccryility <br /> -yy <br /> VECTOR CONTROL PROGRAM(4000) <br /> Poultry Farm Maximum number of birds 0I -I <br /> Kennel rt <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) MAY 5 09 <br /> Tattooing (412 1) Body Piercing (4120) Permanent Cosmetics(4122) <br /> SAN jOAQU4N 0,00NTY <br /> PUSUC HEALTH sEHVICES <br /> LIQUID WASTE PROGRAM(4200) ENb RONMENTAi HEALTH MOON <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 /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility 2—10 generators 11—60 generators >60 generators <br /> Emerp-ency Notification for this FA ILITY and/or PROGRAM <br /> J � <br /> BUSINESS CONTACT PERSON ,d57"2C�L UELLEQ6ay Phone o?D 9�a 7—D3/S Night Phone: <br /> DS}��? <br /> PROGRAM ELEMENT# OO INSPECTOR# � 3 <br /> Permit fee: Permit Valid: to <br /> Food Handlers Course Cash: ,'9 75- <br /> Reviewed by V` Date <br /> 'Accounting Office Date S Invoice# e! '62121 <br /> Rev.04/09/99 <br />