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PA <br /> El New EH Program-at Existing facility Mew EH Program and New Facility <br /> Facility Address 0 P0 <br /> (Please check the appropriate description and specify size, number Of Unita and pertinent information.) <br /> FOOD PROGRAM(1600) 7- <br /> Restaurant: Seating Capacity Ta Square Footage 2_�Z)C, <br /> Food Handlers Course required: YES' No <br /> El Commissary El Dry storage only 1:1 with Food Preparation ElVending Machines Number of Units <br /> 0 Retail Market----Square footage El w/Meat Market only 1:1 Multiple Departments El Prepackaged Goods Only <br /> 11 Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration License# Sticker <br /> Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration License if Sticker# <br /> El Temporary Food Facility--Dates of operation from to ElIce Plant Produce Stand <br /> El Special Event---Dates of operation frorn to El CFO El A El B <br /> DAIRY PROGRAM (2000) <br /> El Grade A Dairy E] Grade B Dairy Milk Dispenser-Nurnber of Containers in Multi-Head Unit <br /> CUPA <br /> [] Hazardous Materials Business Plan (19UO) Number odchenbab: <br /> U Ca|ARPPmgram O Program Facility O Program 2Facility O Program Facility <br /> [] HazaodouoWaste Generator(2280)----------^ Tons Generated Per Yoar1[ <br /> [] Tiered Permitting Facility---'> ElCA (2zJ2) 0oE (2233.2234. 2235.2237) 0PoR (2231) 0Po ^ ��» ^m« � <br /> [] Aboveground Storage Tank Facility (AST) (280O) Number ofASTa <br /> [] Underground Storage Tank Program (U3T) (2300) Use UST A and B forms <br /> -------- <br /> L] Other CUPAProgram �EB 2 3 2019 <br /> HOUSING PROGRAM 2400) <br /> SAN JOAQU/NCOUNTY <br /> Hotel/Motel------Number ofUnits ----- [] Jail o,Exempt Institution ----Number of <br /> n�«� <br /> VIRONMENIAL <br /> Employee Housing (2700) Use Fnnn TH DVtFTATTENT <br /> SITE MITIGATION(23OO) 000> <br /> 1:1Envirnnnnonta|Ass � [] UST-CAP ]� ` <br /> Assessment ' Site LJ Local HVVCleanup Site [] NPL/SEP Cleanup Site [] U|C Site <br /> [] Abandoned HVVSite [] non-NPL/SEP Cleanup Site [] RVVQCB Cleanup Site [] Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (30OO) <br /> Number o[Pun|s/8pasat Facility [] Pool [] Spa [] Out ofService Pool/Spa O Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4UO0) <br /> 0 Poultry Farm-------Maximum number o[birds O Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM («|oo) <br /> El Body Art Practitioner Reg N11N [] Mechanical DGPSNotification (4115) [] Body Art Facility-Single Use (4120) <br /> [] Body Art Facility-Sterilization (4121) [] Body Art Temp Event Co*,d (4130) [] Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM (4200) <br /> 0 Pumper Vehicle nrg/mranon Liconoo# ____________ CapacityVohido# <br /> [] PumporYard El Package Treatment Plant [] Chemical Toilets ----Number ofUnits -------- <br /> SOLID WASTE PROGRAM(44OO) <br /> [] Landfill [] Transfer Station [] Ag/Cannery Waste Site [] Sludge/Ash Site <br /> [] Waste Tire Facility [] Compost Facility [] Pr000us/Rooyc|oFaci|ity [] CIA Landfill Site <br /> [] Refuse Vehicles oa/Units) ______ [] Dumpvtern> 2ncuyd (#orUnits) [] Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (450O) <br /> [] Primary Caro [] Acute Care [] Skilled Nursing [] Largo Generator [] Small Generator [] Limited Hauler <br /> [] Transfer Station [] Veterinary Clinic [] Common Storage Facility [] 2 10 [] 11 60 [] / 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use Fvnn <br /> EMERGENCY NOTIFICATION FOR THj§FACILITY ANWOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br />