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F%- 1868 East Hazelton Avenue <br /> Sian ]oaquin County <br /> Environmental Health Department Stockton,46 -3420 <br /> p Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding P/ Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1QAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> IIIICANT INFORMATION: <br /> R, i 1 iATION: <br /> NAME i 0 _ 1 Phone: 19,09 �16 ` S v <br /> HOME ADDRESS: co v X.0 I G(_i C: i:�V Email: 1 ht, all ca AV na <br /> City: State: �,� Zip: County: <br /> ��R �aa��=���� " ' 6Yi�'�� !'a` �.. •ffio BODYi4R'f PRACTITIONER�flNLY.:E" i�p?�� � a `� �, _.�� *:. <br /> Date of Birth: C-to lio Gender: t7j r M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Y1.. Owner: I k <br /> Address: G i7 li;_(_0h <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: VI C,n VL <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertiflcation of Completed Vaccination 3 MContra Indicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> Ci State: Zip: County: <br /> Owner Contact: D Phone Fax: <br /> 2.BUSINESS NAME: <br /> Location address: Suite: <br /> city; State: Zip: County: <br /> Owner/Contact: Phone/Fax: <br /> The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local <br /> requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that to thest of knowledge and belief the statements made herein are true and correct. <br /> Signature: TIS/ _`J Date: ()CJI - 1), • � Q ' <br /> Print Name: i h VD Title: n uj ii e D___ <br /> FOR OFFICE US6ONLYR i ? tg <br /> "=^+s*` 5 a IRE pie " A6' a era a �9yR i�� <br /> Pr4iararni PE) Rr � ��_ i�ees x A rFzed b)+(REHS)� sir Date Entere � � ii <br /> 2 <br />