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EnvironmentalHealth
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EHD Program Facility Records by Street Name
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ELEVENTH
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18
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4100 – Safe Body Art
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PR0541234
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Entry Properties
Last modified
11/19/2024 10:19:14 AM
Creation date
5/1/2023 3:24:22 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
BILLING/PERMITS
RECORD_ID
PR0541234
PE
4110
FACILITY_ID
FA0023622
FACILITY_NAME
IN BLOOM TATTOO & PIERCING STUDIO (CARBALLO, JOSE)
STREET_NUMBER
18
Direction
E
STREET_NAME
ELEVENTH
STREET_TYPE
ST
City
TRACY
Zip
95377
CURRENT_STATUS
01
SITE_LOCATION
18 E ELEVENTH ST STE B
P_LOCATION
04
QC Status
Approved
Scanner
SJGOV\cfield
Tags
EHD - Public
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SAN JOAQUIN COUNTY E IRONMENTAL HEALTH DEPAR NT <br /> MASTERFILE RECORD INFORMATION FORM PAymENT <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facility RECEIVED <br /> Facility ID -�r4 �( 22- Program Record ID � ` 123 AUG°2 6 2016 <br /> Facility Address SAN JOAQUIN COUNTY <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) ENVIROMENTAL <br /> HEALTH DEPARTMENT <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 ElProduce 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 /> ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> u Hazardous waste Venerator('2200)----------> Tons Venerated 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 B 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 Foram <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP 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) ❑ Body 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 ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd (#of 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 /> E ERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM / <br /> CONTACT PERSON 'SJOSCv-�Oi 10 Day PhM2'5 C Night P z. <br /> PROGRAM ELEMENT FEE L'o 13 Surcharge FEE 13 Other FEE <br /> INSPECTOR# fCX 4' PERMIT VALID 26 �6 to 4- 10 ❑ Food Handler <br /> ElCheck# AMOUNT PAID OcC Date 24 16, INVOICE# <br /> Cash REVIEWED BY ACCOUNTING OFFICEda Date v7STIZ <br /> 48-02-034 MASTERFILE RECOAD INFORMATION PINK <br /> 1/23/13 <br />
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