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COMPLIANCE INFO_MIRANDA CHAVEZ
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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4100 – Safe Body Art
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PR0541380
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COMPLIANCE INFO_MIRANDA CHAVEZ
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Entry Properties
Last modified
10/22/2024 11:00:06 AM
Creation date
5/1/2023 11:26:08 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
FileName_PostFix
MIRANDA CHAVEZ
RECORD_ID
PR0541380
PE
4110
FACILITY_ID
FA0023710
FACILITY_NAME
BLUE MOON TATTOO (CHAVEZ, MIRANDA)
STREET_NUMBER
2306
STREET_NAME
EAST
STREET_TYPE
ST
City
TRACY
Zip
95377
CURRENT_STATUS
02
SITE_LOCATION
2306 EAST ST
P_LOCATION
03
QC Status
Approved
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SJGOV\cfield
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EHD - Public
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1] <br />Hepatitis B Vaccine Declination Form <br />Facility Name: \�`� ®w�.2 <br />Facility Address: <br />I 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, 1 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 />RRA a, & 3&akJ e z,, - <br />Emolovee's Name (Print) <br />Date <br />
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