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SAN JOAQUIN COUNT11 ENVIRONMENTAL HEALTH DEPARTMENT ❑ New EH Program at Existing Facility / Mew EH Program slid New Facility Facility Address u`� ase, (Please check the appropriate descrll (Ion and spedfy W, number of Unita and osrtinanl IUInn HijjW,) FOOD PROGRAM (1000) ❑ Restaurant: Seating Capacity. _ _ Square Footage Food Handlers Course ranulredf Yss ® No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ----Square footage . ❑ wlMeal Markel only ❑ Multiple Depaninonlo ❑ Prepackaged Geode Only ❑ Mobile Food Vehicle -.Make Vohleto Typo _ _ _ _ Color Registration N License N Slicker 8 ❑ Mobile Food Prep Unit- Make _ Vehicle Type Color Registration rlLlcenae N BllCknr N ❑ Temporary Food Facility --Dates of operation from to ❑ toe Plant 5 Produaa Stand ❑ Special Event ---Dates of operation i from to ;'CFO ❑ A jXS DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade 8 Dalry ❑ Milk Dlsponaar-Number of Contnlnoro In Muillhlaad Unit CUPA ❑ Hazardous Materials Business Plan (1000) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility 11 Tiered Permitting Facility -- Hazardous Waste Generatorr ( (222'100) ---------->-Tone Generated Per Year ❑ CA (2232) ❑ CE (2233, 2234, 2238, 2237) ❑ PBR (2231) ❑ FOR HHW (2730) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A arid A farina ❑ Other CUPA Program _ _ _ HOUSING PROGRAM (2400) ❑ HotellMotel----Number of Units ❑ Jell or Exempt Institution ----Number Of Unlln _ Employee Housing (2700) Use Employee Houafna7Labor Coma Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLIBEP Cleanup Site ❑ UIC Siff) ❑ Abandoned HW Site ❑ ,iLon-NPLIBEP Cleanup Site L3RWQCB Cleanup Bite ❑ Water Quality Remodlallon alto RECREATIONAL HEALTH PROGRAM (3000) PAYMENT Number of Pools/Spas at Facility _ L. ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural IlathillibMSIVED VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ® Katmai SEP 2 3 2022 TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) 'AN JOnOUIN COUNTY ❑ Body Art Practitioner Rog (4110) ❑ Mechanical OSPS Notification (4118) ❑ Body AH Foolllty-Singla Use (412gj,'Lv,:RON,MENTAL LNT ❑ Body Art Facility -Sterilization (4121) ❑ Body An Temp Event C"rd (4130) ❑ Body Art -romp Event Mobile Foollity (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistralion i) License N Capaclly, Vablcfo g ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Bile, ❑ Sludge/Ash Slts ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (x of unuel 4_ ❑ Dumpslers > 20 ou yd in of units) _ ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing (3 Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2. 10 ❑ 11 - RO ❑ 9 80 gnnoralors PUBLIC WATER SYSTEM PROGRAM (4800) Use PWS EHD 48.02.002 Blue AoollcaW Form CONTACT PERSON V\ (\-N-QC i Fc. m Day Ph y25 -- kCA- »tllgTd Ph PROGRAM ELEMENT O 9 FEE �f 1 2' 13 Surcharge F ❑ Other FOR INSPEECTOR# L�� PERM VALI0q—Z- —27 t0 q -2. ❑ Food Hay ❑ Check o AMOUNI PAID loZ — Data X) Zz—INVOICE 0 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Gate 46-02-094 MASTHRPILL R6401 Tn9n9J # 15� S)I 17 V 24 zi