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San Joaquin County • 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION RECEA <br /> ���I.PROCEDURES TO BE PERFORMED.Check all that apply (see back for definitions) <br /> Tattooing MBody Piercing Mechanical Stud and Clasp Ear Piercing JAN 12 2017 <br /> Branding Permanent Cosmetics E%"MYEly T <br /> L HSIM <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. Ir$E MES <br /> ioAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[EgAnnual Body Art Facility Permit <br /> III.APPLIC,ANIT INFORMAT�I{-O,N: �Jf1,i <br /> NAME: 1't�\\�� �l'�h� �`�� Phone: <br /> HOME ADDRESS: 1C�o �, ��1(�l-��i^ Email: VICAl ��`�� �L3`(1•CGY1� <br /> City: State: C° A Zip: aZL1l� County: <br /> Date of Birth: L -"� j Gender: F M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Wil b.,e�IProvided }�� ►/ �/� 'y <br /> Facilit Name: '5i C, �y Y Y �C�\�n Owner: e. 1 / k 1 iV V.14� <br /> Address: 5 Q,. ��V► YL�a cJ � (�,k 1 A R52a <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <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 /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[Z]Laboratory Evidence of Immunity 4®Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) r <br /> 1. BUSINESS NAME: �'I:�� G 517 Yc�Z.Vl-A �'Y tYC Y 01- <br /> Location address: 1W5 t"A . �'Cl.� YUP `Jr` Suite: �r.Va <br /> City: 1' l"_�L-"�Cyv'� State: L X�` Zip: e'�52d County: <br /> Owner/Contact: Phone/ Fax: �Uq �i'1C� ' \Oil <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 go erning safe body art pr ctices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby cern hat to,)l e best of k ledge and belief the statements made herein are true and correct. <br /> Signature: `�^-� - Date: 2-" <br /> Print Name: CA Q Title: <br /> If 2 <br />