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Facility Name Address City Zip Code Gypsy Soul Tattoo 118 yosemite ave. Manteca 95336 Name of Permit/Registration Holder Permit Exp. Date Time In Time Out Inspection Type John Holguin Initial Consult. Body Art Inspect Report Date: u!y')S Part 15, C = San Joaquin County Environmental Health Department Program V CLEANING AND STERILIZATION 1868 E. Hazelton Ave., Stockton, CA 95205 Record: 5(L W" ! -r I $ is ar fi e aa` (209)468-3420 www.siogv.org/ehd Program g Element: � 1 U 3 Facility Name Address City Zip Code Gypsy Soul Tattoo 118 yosemite ave. Manteca 95336 Name of Permit/Registration Holder Permit Exp. Date Time In Time Out Inspection Type John Holguin Initial Consult. Reinspecion on/about: A reinspection fee of $130 per hour may be charged. Page 1 of 2 EH -03/2015 The above facility is inspected for compliance with Division V = Violation 104, Part 15, C = Chapter 7 of California Health and Safety Code (HSC). Corrected On Site V CLEANING AND STERILIZATION C V MACHINE SAFETY AND SANITATION (cont.) C ❑ 1 Autoclave: approved and effective - passed integrator test ❑ ❑ 22 Parts replaced between clients - grommets, elastic bands, etc. ❑ ❑ 2' Items washed, disinfected, packaged, labeled, and sterilized ❑ PREVENTING CROSS -CONTAMINATION ❑ 3. Autoclave loaded correctly/packages allowed to dry ❑ ❑ 23. Workstation/procedure area decontaminated ❑ ❑ 4. Integrators used/monthly spore test/log maintained ❑ ❑ 24. Appropriate chemical disinfectant used ❑ El 5' Decontamination/sanitation area separated and supplied ro riatel appropriately ElChemical used: ® 6. 6. Invoices and log kept for disposable, pre -sterilized ui ment El El 25. Disinfectant used appropriately/sufficient contact time ❑ ❑ 7 Sharps containers labeled, used, and disposed of a ro riatel El Wet contact time provided: ❑ 8 Jewelry, tattoo and piercing equipment - clean and sterilized El 26. Barriers used ❑ PRACTITIONER HEALTH AND HYGIENE ❑ 27 Products applied to skin are single use/dispensed aseptically ❑ ❑ 9. No eating, drinking or smoking - clean clothes ❑ ❑ 28. Storage of inks, pigments, needles, tubes, etc. ❑ ❑ 10. Hands washed effectively and timely ❑ ❑ 29. Jewelry, Inks, Needles etc approved and used correctly ❑ ® 11' Handwashing facilities properly supplied and accessible, warm water El [1 30. Cross -contamination avoided during all phases of procedure ❑ ❑ 12. Hepatitis B vaccination ❑ BEST BUSINESS PRACTICES ® 13_ Bloodbome Pathogen trainingElElEl31. Areas separated/no living or sleeping quarters Source: ® 32. Floors and walls clean and in good repair, adequate light ❑ ❑ 14. Appropriate personal protective equipment available and ❑ ❑ 33 Workstation, surfaces, including chairs, armrests, etc. in good repair Elused CUSTOMERSICLIENTS ® 34. Permit/registration posted ❑ ❑ 15. Branding is completed with no other customers in rocedure area El® 35. Operation and employee training records present ❑ ❑ 16. Customers eighteen (18) years of age or older ❑ COMPLIANCE AND ENFORCEMENT ❑ 17. Skin adequately prepared for procedure ❑ ❑ 36. Plan(s) submitted for review ❑ ® 18 Client records approved and available - Consent form and questionnaire ❑ [137. Permits obtained and available E] ® 19. Appropriate aftercare instructions given to client ❑ ❑ 38. Impoundment ❑ MACHINE SAFETY AND SANITATION ❑ 39. Hearing scheduled ❑ ❑ 20. Safe machine design ❑ ❑ 40. Closure ❑ ❑ 21. Machines cleaned and disinfected between clients ❑ ❑ 41. ❑ Received b (Print): John Holguin Received by (Signature): Phone: 209) 239-0800 Specialist (Print): Benjamin Escotto, Sr REHS Specialist (Signature): Phone: 209 468-3178 Reinspecion on/about: A reinspection fee of $130 per hour may be charged. Page 1 of 2 EH -03/2015