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Body Art Inspect Report Date: 1 <br /> ll�k/I <br /> San Joaquin County Environmental Health Department Program `, <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: l ' 7 <br /> �. (209)468-3420 <br /> F... www.siogv.org/ehd Program <br /> Element: (o Z <br /> PR Number PRACTITIONER/ARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> PRO541622 Erica Green-Frese <br /> Observations and Corrective Actions: <br /> 6. A facility that uses single use instruments shall maintain record of purchase, log of procedures, names of practitioner and <br /> client, date of procedure, instruments used, and written evidence from the manufacture that the instruments have undergone <br /> sterilization. The record of purchase, evidence of sterilization, type and number of instruments used shall be maintained for a <br /> minimum of 90 days after use. HSC 119315(f)Submit certificate of sterilization to EHD within 30 days. Ensure lot number <br /> on needles matchs certificate of sterilization. <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 Ensure a photo copy of the client's driver license is included with the forms.Submit <br /> client consent form and medical questionnaire with photo copy of the client's driver license to EHD within 30 days. <br /> J <br /> Reinspecion on/about: A reinspection fee of$130 per hour may be charged. Page 2 of 2 <br /> EH-03/2015 <br />