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COMPLIANCE INFO
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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E
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ELEVENTH
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18
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4100 – Safe Body Art
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PR0548549
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COMPLIANCE INFO
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Entry Properties
Last modified
11/19/2024 10:19:27 AM
Creation date
8/11/2023 1:56:39 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0548549
PE
4110
FACILITY_ID
FA0027754
FACILITY_NAME
IN BLOOM TATTOO & PIERCING (DIGIALLONARDO, ZACHARY)
STREET_NUMBER
18
Direction
E
STREET_NAME
ELEVENTH
STREET_TYPE
ST
City
TRACY
Zip
95376
CURRENT_STATUS
01
SITE_LOCATION
18 E ELEVENTH ST
P_LOCATION
03
QC Status
Approved
Scanner
SJGOV\cfield
Tags
EHD - Public
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Facility ID# <br />Program ID# <br />Hepatitis B Declination Statement <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. I <br />have read and understand the health risks involved with Hepatitis B; however, I <br />voluntarily decline Hepatitis B vaccination at this time. I fully understand the risk of its <br />transmission and have full knowledge of its effects on the human body. I understand <br />that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious <br />disease. <br />SIGNATURE: (-� - DATE: A _ <br />PRINT NAME: 2- D tL—r tw+kof,)A-Q-0� <br />ADDRESS: `L(p p ca-eSTF-o CITY: MpuL7S,v STATE C4- ZIP <br />Toa W M mc1 ST. <br />W'Vata1EH-PROGRAMS & PROJECTSIBODY ARWORMS\WORD DOCSWEPATITIS 8 DECLINATION STATEMENT, 4 23 13.docx <br />
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