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Body Art InspectiOReport • Date: 9�G/I 9 <br /> rr ? San Joaquin County Environmental Health Department Program <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: ;5 ZOO a l 0 q 5 <br /> � = (209)468-3420 Pro <br /> gram <br /> o'F`'`P e www.siogv.org/ehd Element: <br /> PR Number PRACTITIONER/ARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> K mberlei h Thompson BBP exp.6/26/20 <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). —Provide the EHD with a correspondence from blade manufacturing <br /> correlating blade lot number with sterilization certificate. <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. —Include the following statement in the medical questionnaire: history of allergic <br /> reactions to antibiotics. <br /> Pay permit fees prior to scheduling final inspection. <br /> Reinspecion on/about: A reinspection fee of$162 per hour may be charged. Page 2 of 2 <br /> EH-11/17 <br />