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COMPLIANCE INFO_KRISTAL BETANCOURT
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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C
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4100 – Safe Body Art
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PR0539346
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COMPLIANCE INFO_KRISTAL BETANCOURT
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Entry Properties
Last modified
8/21/2023 3:16:23 PM
Creation date
3/13/2023 3:09:51 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0539346
PE
4110
FACILITY_ID
FA0022495
FACILITY_NAME
12 MONKEYS TATTOO STUDIO (BETANCOURT, KRISTAL)
STREET_NUMBER
911
Direction
N
STREET_NAME
CENTRAL
STREET_TYPE
BLVD
City
TRACY
Zip
95376
APN
23505611
CURRENT_STATUS
01
SITE_LOCATION
911 N CENTRAL BLVD
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
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SJGOV\cfield
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EHD - Public
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Hepatitis B Vaccine Declination Form <br />Facility Name: <br />Facility Address: <br />/ 2 M 0NKC + S T�TTID� <br />q C 1. N. c- FN-tzj -t_ 6( --VT). -MAL v C A L <br />understand that due to my occupational exposure to blood or other potentially <br />infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. <br />I have been given the opportunity to be vaccinated with the hepatitis B vaccine, <br />at no charge to myself. <br />However, I decline hepatitis B vaccination at this time. I understand that by <br />declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious <br />disease. If, in the future, I continue to have occupational exposure to blood or <br />other potentially infectious materials, and I want to be vaccinated with hepatitis B <br />vaccine, I can receive the vaccination series at no charge to me. <br />Employe 's N e (Print) <br />i <br />Employee's Skature <br />l31 <br />Dat <br />
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