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�. SJ COUNT"rEIA*fk6j MENTAL HEALTH DIVISION <br /> ,MAj&RFILE RECORD INFORMATION FORM 0 69) <br /> New EH Progr ing Facility New ogram/New Facility <br /> Facility ID#: Program Record ID#: !6- <br /> FOOD <br /> FOOD PROGRAM(1600) <br /> Restaurant -- Seating Capacity Square Footage Produce Stand I cc 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 <br /> HOUSING PROGRAM(2400) <br /> Hotel/Motel Jail or Exempt Institution Number of Units <br /> SITE MITIGATION(2900) <br /> RECREATIONAL HEALTPROGRAM(3600) <br /> Pool Spa Out of Service Pool,'Spa Natural Bathing Area Number of PooWSpas at Facility <br /> VECTOR CONTROL PROGRAM(4000) <br /> Poultry Farm Maximum number of birds Kennel <br /> TATTOO, IERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> Tattooin (4121) 7 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 D umpsters>20 cu yd Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> Primary Care Acute Care Skilled Nursing L arge Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility 2—10 generators 1 1 —60 generators > 60 generators <br /> Emergency Notification for this FACILITY and/or PROGRAM <br /> BUSINESS CONTACT PERSON: 0 N ki2rg/_A Of) Dav Phone: 20e3 — $3°{-Ja5 Night Phone: E(.Z` -1-155 567f. <br /> PROGRAM ELEMENT# INSPECTOR# <br /> Permit fee: Permit Valid. to <br /> Food Handlers Course Check/Cash: C <br /> Reviewed by ��W ` Date D4 <br /> J� <br /> Accounting Office Date Invoice# <br /> Rev. 02/01/99 <br />