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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION ❑ New EH Program at Existin Facility ID On�b EH Record ID and New Facil RF YMENT /SCE/V 6 Facility Address Authentic Images Tattoo & Piercing, 2139 Jackson Avenue, Esealon, CA 95320SA �w U 9020 (Please check the appropriate description and specify size, number of units and pertinent information) N JOAQU/ c FOOD PROGRAM (1600) �Ak V IRONM COEIVUNp El Restaurant: Seating Capacity. Square Footage Food Handlers Course required: y 1)'NE (t'A❑ ❑ 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 Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200)----------> - Tons Generated Per Year. ❑ Tiered Permitting Facility --- ---> ❑ CA (2232) ❑ CE (2233, 22349 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units _ Employee Housing (2 100) Use Employee Housinq/Labor Camp Application Form _ 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) ❑ Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) LJ Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License # ❑ Capacity Vehicle Pumper Yard ❑ Package Treatment Plant # ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑Transfer Station ❑ AglCannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler O Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators 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 S233❑Surcharge FEE ❑ Other FEE INSPECTOR # PERMIT VALID LD t0 Food Handler ❑ Check # J1�,5A AMOUNT PAID :' > .� Date K ❑ Cash REVIEWED BY ACCOUNTING OFFICE 1,1 ❑ INVOICE # G I Date 8 48.02-034 n MASTERFILE RECORD INFORMATION PINK 1!23/13 �� , l �