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SJ COUNT�� ,ENVIRONMENTAL HEALTH IVISION <br /> MASA*rFILE RECORD INFORMATION FORM (E6*�69) <br /> it <br /> New EH ProgramNe <br /> /Existing Facility w EH iogram/New Facili <br /> Program Record ID#: <br /> Facility ID#: <br /> I <br /> FOOD PROGRAM(1600) <br /> Square Footage Produce Stand:: Ice Plant <br /> Restaurant - Seating Capacity 4 Vending Machines Numbers of Unit <br /> Commissionary Dry storage only with Food Preparation <br /> Retail Market Square footage with Meat Market only Multiple lDepartments PreQackaged Goods Only <br /> Color: <br /> MVehicleType:_��..obile Food Facilities Make: Sticker# IG <br /> Registration#: License#: �r <br /> Vehicle Type: Color: <br /> Mobile Food Prep Unit Make: Sticker# r <br /> Registration#: License#: <br /> Temporary Food Facility Dates of operation: from <br /> to <br /> Special Event Dates of Operation: from: to <br /> DAIRY PROGRAM (2D00} (Please mark the appropriate description and specify size and/or humbler of units where applicable.) <br /> Grade A Dairy Grade B Dairy Mille Dispenser Number of Containers in Multi-Head Unit:1� <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> Hazardous Waste Generator Tons generated per year Conditionally Exei pt Permit by rule <br /> Tiered Permit Facility Conditionally authorized <br /> i <br /> HOUSING PROGRAM(2400) <br /> Hotel/Motel Jail or Exempt Institution Number of Units <br /> s SITE MITIGATION(2900) :Ot2)[ <br /> RECREATIONAL HEALTH PRO <br /> Pool spa Out of Service Pool/Spa Natural Bathing Area Number of Pools/Spas at Facility <br /> VECTOR CONTROL PROGRAM(4000) Kennel <br /> Poultry Farm Maximum number of birds��� <br /> TATTOO,BODY PIERCING,PERNIANENT COSMETIC PROGRAM(4 100) <br /> Tattooing (4121) Body Piercing (4120) Permanent Cosmetics(4122) <br /> a <br /> LIQUID WASTE PROGRAM(4200) Ca aci Vehicle# <br /> Pumper Vehicle Registration# License# P tY--�— <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 /> Com ost Facility Refuse Vehicles Number of Units <br /> CIA Landfill Site Sludge/Ash Site P �G <br /> cle FacilityDumpsters>20 cu yd Number of Units <br /> Process/Rec <br /> Waste Tire Facility Y <br /> I <br /> MEDICAL WASTE PROGRAM(4500) Skilled Nursing Large Generartor <br /> Primary Care Acute Care <br /> Small Generator Transfer Station Limited Hauler Veterinary Clinic <br /> Common Storage Facility 2– 10 generators !!–60 generators >60 generators <br /> I <br /> Emer encu Notification for this FACILITY and/or PROGRAM j <br /> �/ Da Phone: �' — Night Phone: <br /> BUSINESS CONTACT PERSON: y <br /> {� INSPECTOR#� 41 <br /> PROGRAM ELEMENT# — I� <br /> Permit Valid: CO <br /> Permit fee: I <br /> Food Hanc/ers Course 9'D DecCash: j <br /> Reviewed by <br /> Date_ <br /> Accounting Office <br /> Date ' r Invoice# O dt y'3 j <br /> I <br /> Rev.04/09/99 j <br /> i <br />