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y �. Body Art Inspect Report Date: <br /> San Joaquin County Environmental Health Department Program <br /> ` 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: S Q.p0O5g1'7 <br /> (209)468-3420 <br /> www.siogv.org/end Program LiIO.L <br /> Element: <br /> PR Number PRACTITIONER/ARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> PRO541299 Tina Phon <br /> Observations and Corrective Actions: <br /> 18. The facilities client consent form and medical questionnaire must include all of the information listed in Form B, <br /> and are available for inspection. HSC 119303-Medical questionnaire does not mention cardiac valve disease. <br /> Shop may now open. Submit evidence of corrective action <br /> for the above mentioned observation prior to the routine <br /> I <br /> inspection. <br /> Reinspecion on/about: A reinspection fee of$130 per hour may be charged. Page 2 of 2 <br /> EH-03/2015 <br />