Free 47626.PDF - Indiana

REPORT OF TANNING FACILITY INSPECTION
State Form 47626 (R2 / 5-00) INDIANA PROFESSIONAL LICENSING AGENCY 302 West Washington Street, Room E034 Indianapolis, IN 46204 Name of facility Inspections this licensing period License number

License Civil Penalties
Date (month, day, year) County

Withheld Enforce

Location

Name of owner

Name of manager

Telephone number

Address (number and street)

(
Former owner and/or name

)
City and state ZIP code

Number of devices

T elephone number

(
LICENSE: Application Submitted Properly Licensed NOTIFICATION: Proper notice of new sunlamp products Notification of changes in facilities/operating procedures CONSUMER PROTECTION: Consumers Instructed Exposure Distance Lamps Shielded Exposures Limited Lamps Filters Displayed EQUIPMENT CONSTRUCTION: DesignMechanical Safety LABEL REQUIREMENTS: Warning Statement - Danger Legible How Measured Warning - Protective Eyewear Warning - Maximum Exposure Time Exposure Schedule Misleading Statements DEVICE LABELS: Compliant Manufacturer's Name and Address Month/Year manufactured Model/Type Body Contact Surfaces Sanitized Single Use T oweling Provided WRITTEN RECORDS Written Warning Statements Assurance of Notification Signed Visits Recorded Exposure Times Recorded Records Kept Maintained Serial Number Legible Lamp Types Minimum Exposure Distance Electrical Safety

)
USERS INSTRUCTIONS: Provided by Manufacturer Available to Consumer Exposure Recommendations Contains Warning Label Instruction for Replacement Parts WARNING SIGNS: Properly Located Proper Size OPERATORS: Operators Trained List Maintained INJURY REPORT : Filed 7 Days Written Legible ADVERTISING: No Safe or Free of Risk Claims No Promotion of Unlimited Use 48 Hours / Telephoned List Provided Legible Properly Worded

Proper Access and Support

T emperature Emergency T elephone List Controlled PROTECTIVE EYEWEAR: Adequate Number Eyewear Used SANITIZATION: Proper Sanitizer Eyewear Sanitized Sanitizer T Kit est TIMER SYSTEM: Timers exceed maximum recommended exposures Proper Timers Graduations Consistent with Exposure Schedule Timer Error Less Than 10% TERMINATION CONTROLS: Consumer Termination Control Operator T ermination Control Approved Remarks: * Pending Closed

Time to Expect Results

CERTIFICATION LABELS:

Customer Address, Telephone, Age Recorded PARENTAL CONSENT Persons less than 18 years: written parental consent provided Persons less than 16 years accompanied by parents Disapproved Out of Business Terminated

WARNING: The continued violation may result in the assessment of civil penalties.
Name of Inspector Date received by owner/operator (month. day, year) Date follow-up(month. day, year)

* Date of follow-up must be indicated.
DISTRIBUTION: White - Professional Licensing Agency; Canary - Inspector; Pink - Tanning Facility