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Body Art Inspecti 2eportDate: LI /3o / <br /> San Joaquin County Environmental Health Department Program u <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: 1 2 <br /> (209)468-3420 Program <br /> www.siogv.org/ehd Element: 1 PIG�42'0'_ <br /> � <br /> PR Number PRACTITIONERIARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> PRO544301 Tanya Vrismo <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(D—Provide evidence of sterilization for the blades and needles. Provide <br /> record of purchase for the blades and needles. Include the lot number of the blade/needle with the client records. <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 all the requirements in Form B in the medical questionnaire. Provide a <br /> copy to the EHD. Form B was provided to the practitioner. <br /> Note: <br /> 1. Provide a copy of the updated medical questionnaire to the EHD. <br /> 2. Provide a copy of the sterilization cetification for the blades and needles. <br /> Unless otherwise noted, correct all violations prior to the issue of the practitioner permit. <br /> Reinspecion on/about: A reinspection fee of$152 per hour may be charged. Page 2 of 2 <br /> EH-11/17 <br />