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Body Art Instion Report <br /> Date: la I30 I 1 9 <br /> t San Joaquin County Environmental Health Department Program <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: N B hi PR <br /> (209)468-3420 Program <br /> C'9( FQRd`P• www.5109y.orq/ehd Element: NlezO <br /> PR Number PRACTITIONERIARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> Laisin Saetern(BBP exp.9/29/20)BBP and permit <br /> PRO544903 posted <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, and are <br /> available for inspection. HSC 119303—The medical questionnaire did not include all of the information listed on Form B. <br /> Include"other risk factors for Bloodborne pathogens"on the medical questionnaire. Provide a revised copy of the <br /> medical questionnaire to the EHD. <br /> Notes: <br /> 1. Facility may now begin operation. <br /> 2. Pay all applicable fees to the EHD. <br /> 3.Sharps waste disposal is required annually or when the container is full. <br /> 4. One of two rooms is occupied, both rooms were inspected. Stock the unoccupied room with paper towels and <br /> soap prior to use. <br /> Reinspecion onlabout: A reinspection fee of$152 per hour may be charged. Page 2 of 2 <br /> EH-11/17 <br />