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4100 – Safe Body Art
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PR0541158
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Entry Properties
Last modified
9/13/2024 2:54:34 PM
Creation date
4/6/2023 11:16:23 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
BILLING/PERMITS
RECORD_ID
PR0541158
PE
4120
FACILITY_ID
FA0023568
FACILITY_NAME
LIVING WATER STUDIOS (SHEA, THOMAS)
STREET_NUMBER
210
Direction
N
STREET_NAME
MAIN
STREET_TYPE
ST
City
MANTECA
Zip
95336
CURRENT_STATUS
01
SITE_LOCATION
210 N MAIN ST
P_LOCATION
04
QC Status
Approved
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EHD - Public
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NTYrNVI <br /> N MENTAL <br /> LTH <br /> SAN JOAQUINMCOUE FILE RECORORD NFORMAT oNF ORM <br /> DEPARTMENT pAY�� <br /> RE NT <br /> New EH Program at Existing Facility ❑New EH Program and New Facility SEPC�we® <br /> Facility ID 00 o a-7 3'7 Program Record ID - SAN'Jp UI 4 2415 <br /> 0NVAQUAV COU <br /> Facility Address V3'71 C.�Jb n-�; �, (�v�C�uo'�'e�rrn °� 53�1p y�q�rH QCOIMY <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) PgRr�E <br /> FOOD PROGRAM (1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--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 ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business Plan(1900) Number of chemicals: <br /> ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233,2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br /> ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST) (2300) Use UST A and S forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-------Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) <br /> Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115)IKBody Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) <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 ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles (#of Units) ❑ Dumpsters>20 cu yd (#or Units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large 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 PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON f1 Day Ph Night Ph <br /> FNSPECTOR# <br /> ELEMENT ��V 'Li <br /> 1� FEE ❑ Surcharge FEE ❑ Other FEE _ <br /> O PERMITVALID ,St0 {p ❑ Food.HandlerAMOUNT PAIDh 3 .dD Date INVOICE# <br /> ❑ Casl-i REVIEWED BY i3c 9/115�IS ACCOUNTING OFFICE Date <br /> 48-02-034 MASTERFILE RECO ,D INFORMATION PINK <br />
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