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SJ COONS ENVIRONMENTAL HEALT IVISION <br /> MAS FILE RECORD INFORMATION FORM (�69) <br /> New EH Program/Existing Facility New EH Program/New Facility <br /> Facility IDN: �� `J a a'O 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 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-l-lead Unit: <br /> HAZARDOUS WASTE PROG 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 /> Ilotel/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 /> VECTOR CONTROL PROGRAM(4000) <br /> Poultry Farm Maximum number of birds Kennel <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 /> PAYMENSI <br /> MEDICAL WASTE PROGRAM(4500) PFF+F-II6P-5':, <br /> Primary Care Acute Care Skilled Nursing L arge Generator <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic � s 1� <br /> Common Storage Facility 2–10 generators 1 I –60 generators > 60 generators <br /> SAh!JOAQUIN CUUNTY <br /> Emergency Notification for this FACILITY and/or PROGRAM PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIOi <br /> BUSINESS CONTACT PERSON: M,�l Day Phone: F 4 -1 – /8S Z Night Phone: 4 6 6–Z l V l <br /> PROGRAM ELEMENT# INSPECTOR#-(7�CQ <br /> Permit fee: ��— Permit Valid: 4P//& req to 3 31 1`7 <br /> 1U .UO ria - reE'er , , <br /> Food Handlers�urse Check/Cash: alt t e. G�a�� <br /> Reviewed by �- 1 Lk a,�:: " Date S f <br /> Accounting Office 116 Date q Invoice# <br /> Rev.02/01/99 <br /> to l7 y <br />