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UtV` <br /> lo° "' •co- god Art Inspection Report <br /> y ns p onDate: Aril 13,2022 <br /> it {1 San Jcaquin County Environmental Health Department Program p <br /> 1868 E.H azelton Ave.,Stockton,CA 95205 <br /> (209)4EE.-3420 Record: PR0546977 <br /> .: <br /> j <br /> ``o • P.-' www.siccv.org/ehd Program <br /> 4 /F c ii? Element: 4120 <br /> Facility Nane Address City Zip Code <br /> Pure Form Gallery&Tattoo 213 W.Yosemite Ave Manteca 95336 <br /> Name of Permi'/Registration F-osier Permit Exp. Date Time In Time Out Inspectioi Type <br /> William Ec gington 6/30/22 Routine <br /> The above facility is inspected for compliance with Division 104, Part 15, Chapter 7 of California Health and Safety Code(HSC). <br /> V=Violation C=Corrected On Site <br /> V CLEAVING AND STERILIZATION C V MACHINE SAFETY AND SANITATION cont. C <br /> Parts replaced between clients-grommets.elastic bands, <br /> ❑ 1. Autoclave: approved and effective-passed integrator test ❑ ❑ 22 i etc_. 11 <br /> Items washed,disinfected, packaged, labeled, and <br /> El 2. sterilized El CROSS-CONTAMINATION <br /> ❑ 3. Autoclave loaded co rectly/packages allowed to dry ❑ ❑ 23. Workstation/procedure area decontaminated ❑ <br /> ❑ 4. Integrators used/monthly spore tesUlog maintained ❑ 24. Appropriate chemical disinfectant used <br /> Decontamination Isar itation area separated and supplied ❑ ❑ <br /> ❑ 5. appropriately ❑ Chemical used: <br /> ® <br /> Invoices and log kep:for disposable, pre-sterilized 6. ❑ El25. Disinfectant used appropriately/sufficient contact time Elequipment <br /> Sharps containers labeled, used,and disposed of <br /> ❑ 7' a ro riatel El [Wet contact time provided: <br /> ❑ <br /> Jewelry,tattoo and aercing equipment-clean and 8. El El 26. Barriers used Elsterilized <br /> PRACTITIONER HEALTH AND HYGIENE ❑ 27. Products applied to skin are single use/dispensed aseptically ❑ <br /> ❑ 9. No eating,drin<ing or smoking-clean clothes ❑ ❑ 28. Storage of inks, pigments, needles,tubes,etc. ❑ <br /> ❑ 10. Hands washed e-fec ively and timely ❑ ❑ 29. Jewelry, Inks, Needles etc approved and used correctly ❑ <br /> Handwashing facilities properly supplied and accessible, <br /> ❑ 11. hot water ❑ ❑ 30. Cross-contamination avoided during all phases of procedElure <br /> ❑ 12. Hepatitis B vac.cinati)n ❑ BEST BUSINESS PRACTICES <br /> ® 13. Bloodborne Pathoge-i training El <br /> 31. Areas separated/no living or sleeping quarters ❑ <br /> Source: ❑ 32. Floors and walls clean and in good repair,adequate light ❑ <br /> Appropriate persona protective equipment available and Workstation, surfaces, including chairs,armrests,etc. n <br /> F] 14. used El ❑ 33' ood repair <br /> El <br /> CUSTOM ERS/CLI ENTS ® 34. Permit/registration posted ❑ <br /> Branding is completed with no other customers in <br /> El 15. El El® 35. Operation and employee training records present <br /> procedure area <br /> ' s :x ' a <br /> ❑ 16. Customers eighteen(18)years of age or older ❑ OMPkIi[ CE=AND_ENFlRC1=RIf=N`T <br /> ., <br /> ❑ 17. Skin adequately orepared for procedure ❑ ❑ 36. Plan(s)submitted for review ❑ <br /> Client records app-oved and available-Consent form and questionnaire <br /> El® 18. L1 El 37. Permits obtained and available <br /> ❑ 19. Appropriate aftercare instructions given to client ❑ ❑ 38. Impoundment ❑ <br /> MACHINE SAFETY AND SANITATION ❑ 39. Hearing scheduled ❑ <br /> ❑ 20. Safe machine design ❑ ❑ 40. Closure ❑ <br /> ❑ 21. Machines cleaned aid disinfected between clients ❑ ❑ 41. ❑ <br /> Received by(Print): William Edgington Received by(Signature): EMAILED Phone:209-204-9925 <br /> Specialist Print): Pinne Chao Specialist(Signature): Phone:209-468-3854 <br /> Reinspection on/about: A reinspection fee of$152 per hour may be charged Page 1 of 2 <br /> EH-11/17 ( _� <br />