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SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT <br /> � m*o/cnn�cnc�umu /n�u�woA/mmFunxo <br /> New EH Proqrarn at Existing Facility DSNew EH Program and New Facility' <br /> Facility Address IAC3 CAUJ�p _A-4 e.. LoA`1 <br /> (Please check the appropriate description and specify size. number of units and pertinent information.) <br /> FOOD PROGRAM (160D) <br /> [] Restaurant: Seating-CapmCi'y____ Square Footage � FoodHandlereCouroe [equiret YES [] No [] <br /> El Commissary [] Dry storage only [] ai1hFood Preparation []VendingMachines Number ofUnits <br /> [] <br /> Retail Market----Square footage [] *YMeat Market only [] Multiple Departmenin [] Prepackaged <br /> Mobile Food Vehicle--Make ^ Vehicle Type Color <br /> Registration# License# Sticker# <br /> E3 Mobile h8obi|e Fnod Prep Unit--Make Vehicle Type Color <br /> Registration# Liconae# Sticker <br /> [] Temporary Food Fsd|ity —Oa1eoofoperation from to �����---- El Ice Plant El Produce Stand <br /> [] <br /> Special Event---Dates of operation from to [] CFO [] A [] B <br /> DAIRY PROGRAM (c«»») <br /> [] Grade Dairy [] Grade B Dairy [] K0Uh Dispnnner'MumberofContainers in Multi-Head Unit_____ <br /> CUPA <br /> 6u--wazordouoMaterials Business Plan (19OD) Numberofohemioa|s. <br /> [] Ca|ARP Program [] Program 1 Facility [] Program 2 Facility [] Program 3 Facility <br /> [] HazardoueWaste Generator(22UO)----------> Tons Generated Pei-Year <br /> [] Tiered Permitting Facility -------> [] CA (2232) [] CE (2233, 2234� 2235. 2237) [] P8RPBRHHVYt223O) <br /> [] AbovegnoundStorage Tank Facility (A3T) (28OO) Number ofASTs________ <br /> [] <br /> Underground Storage Tank Program (UST) (2300) Use <br /> [] Od`e,CUPA P,oQ,an` <br /> HOUSING PROGRAM (24O0) <br /> [] Hotel/Motel------NumUe,ofUnits [] Jail orExempt Institution ----Number ofUnits <br /> __________ <br /> Employee Housing (27OO) Use Employee HousinglLabor Camp Application Form <br /> SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> [] Environmental Assessment [] UST'CAPSite [] Lona[ HYVCleanup Site [] NPL/SEP Cleanup Site [] U|C Site <br /> [] Abandoned HVVSite [] non-NPL/SEP Cleanup Site [] RVVOCB Cleanup Site [] Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3000) <br /> AumberofPools/Spas at Facility [] Pool [] Spa [] Out ofService Pool/Spa [] NafUra| Bathing Area <br /> VECTOR CONTROL PROGRAM (4OOO) <br /> [] Poultry Farm-------Maximun1number ofbirds [] Kennel <br /> TATTOO. BODY PIERCING.PERMANENT COSMETIC PROGRAM (410O) <br /> LJ Body Art Practitioner Reg (4110) [] Mechanical DSPSNotification (4115) [] Body Art Facility-Single Use (4120) <br /> [] Body Art Facility-Sterilization (4121) [] Body Art TennpEvent Co-ondm130, [] Body Art-TempEvent Mobile Facility (.4131` <br /> LIQUID WASTE PROGRAM (42OO) <br /> [] Pumpe,Vehio|eRegist,adon# Lioonms# Capacity Vehide#_________ <br /> [] Pumper Yard [] Package Treatment Plant [] Chemical Toilets ----Number ufUnits <br /> SOLID WASTE PROGRAM (44OD` <br /> [] Landfill [] Transfer Station [] Ag/Cannery Waste Site [] Sludge/Ash Site <br /> [] Waste Tire Facility [] Compost Facility [] Process/Recycle Facility [] CIA Landfill Site <br /> [] Refuse Vehicles <�_-'unx,� [] Dumpotem> 20 cu yd .v'u"ts _____ [] Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (45O0) <br /> [] Primary Cure [] Acute Cane [] Skilled Nursing [] Large Generator [] Small Generator [] Limited Hauler <br /> [] Transfer Station [] Veterinary Clinic [] Common Storage Facility [] 2 10 [] 1| OO [] " 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use Foil?) <br /> EMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br />