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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT New EH MASTERFILE RECORD INFORMATION FORM Facility Address Authentic Irnayes Tattoo R Piercing, 213J JaLkbull AVenuu, Escalon, CA 95320 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) R�� MENT E/ QED AUG 04 2020 HE H ONMENTUNTy QEPARTMENT ❑ Restaurant: Seating Capacity Square Footage_ Food Handlers Course required: YEs ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration # _ License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in MuitkHead Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Hazardous Waste Generator (2200) ---------->-Tons Generated Per Year ❑ Tiered Permitting Facility ---- -> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑PBR HHW (2236) HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2100) Use Employee Housinq/Labor Camp Application l-onn SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑Pool ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) LJ Body Art Practitioner Reg (4110) 11 Mechanical DSPS Notification (4115) El Body Art Facility -Single Use (4120) ❑ Body A"[: mt et ;1; 6; (4121) ❑Body Art Temp Event Co-ord (4130) ❑Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) O Landfill ❑ Trans fer Station LJ Waste Tire Facility LJ Compost Facility 11 Refuse Vehicles I# of Units) Capacity Vehicle # 11 Pumper Yard ❑ Chemical Toilets ----Number of Units 13 AglCannery Waste Site ❑ ProcesslRecycle Facility ❑ Dumpsters > 20 cu yd (tf of Units) 11 Sludge/Ash Site ❑ CIA Landfill Site ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care 11 Acute Care El Skill Nursing 11 Large Generator El Sm Generator ❑ Transfer Station LiVeterinary Clinic Li Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 Li PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT FEE S152 171Surchar INSPECTOR # - " )+Vh PERMIT VALID F14A7 C) to �, ❑ Check # S AMOUNT PAID , Date ❑Cash REVIEWED BY 48-02.034 1 /23/13 ACCOUNTING OFFICE 11 Other FEE 11 Limited Hauler > 60 generators 11 Food Handler _ INVOICE # � Date ?-�j MASTERFILE RECO D INFORMATION PINK