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SJ COUNO ENVIRONMENTAL HEALT*IVISION <br /> MASTERFILE RECORD INFORMATION FORM (E O 69) <br /> �,.,,�y <br /> N- 4f Program <br /> Program/Existing Facility New EH Program/New Facility <br /> Facility ID#: 060/ 7 f Program Record ID#: <br /> FOOD PROGRAM(1600) 151 g5 <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 -FN-umbye�r of Containers in Multi-Head Unit: <br /> HAZARDOUS WASTE PROGRAM(2200) \A S I)PI' Q�j�� }�, -, ,, D � � <br /> Hazardous Waste Generator <br /> Tons generated per year �-�" D� �d�/o'" f <br /> Tiered Permit Facility Conditionally authorized Conditionally Exe Permit by rule <br /> 'HOUSING PROGRAM(24(X)) <br /> Hotel/Mutel Jail or Exempt Institution Number of Units �`Q <br /> i 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 Kcnnct <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> Tattooing (412U Body Piercing (4[20) 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 /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility 2- 10 generators I I -60 generators >60 generators <br /> Emergency Notification for this FACILITY and/or PROGRAM <br /> BUSINESS CONTACT PERSON:DALUIV/uJ�F-P, S. Day Phone:`� fNight Phonec3LU�)3 <br /> L5 it oC)fi <br /> PROGRAM ELEMENT# adetQ 390 INSPECTOR# Pa-'P Kir' CY.MA <br /> Permit fee: Permit Valid: to <br /> Food Handlers Course Check/Cash: <br /> Reviewed by Date <br /> Accounting Office Date K 2,1 Invoice# <br /> Rev.04/09/99 <br />