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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> 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. PROCEDU TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing ®Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics <br /> II. REQUIRE REGISTRATION,PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 102rAnnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III.APPLICANT FORMATION <br /> NAME: I L Phone. <br /> HOME ADDRESS: L//3 4a la.-E c?P l Email: <br /> City:, State: ew Zip: County: log qW <br /> BOD. SART PRACTITIEW,0i Y <br /> Date of Birth: ®/ -- Gender: F or rn (circle one) <br /> Identification Type: rivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: C7 Owner: <br /> Address: 3L1` r J <br /> Evidence of Six-months of Related Experience <br /> Facility Name: ✓r; r Owner: a <br /> Address: ���► ®` <br /> Service You Provided: Ziz/10c) <br /> Supervisor Name and Contact Information: i C <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: –?–Z3—/27 Training Provided b J/ ®-W'4 vi <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: f-__ i L <br /> Location address: ` $ Suite: <br /> City: State: Zip: Count OCL (j <br /> C SaAfizALPhone 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 s dy art practi r practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that th ;O; k e4Se and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: g,j2jg,Z,6,® Title: �el— <br /> Ced <br /> �A t oy(RE Iff <br /> S) D�§n �e ��� <br /> f2 <br />