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• San ]oaquin 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 /> I MECHANICAL EAR PIERCING FIC <br /> � i7umx <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing dy Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUI13ED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> Tj!gLAnnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> Annual Body Art Facility Permit <br /> A INFORMATION: <br /> Phone: 201 VP3- <br /> <br /> <br /> <br /> Ot'7t1f' T`IP I.Y <br /> Date of Birth: , Gender: F r M (circle one) <br /> Identification Type: rivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Ce,' }Lb&C Owner: tJ $I 4 <br /> 2 <br /> Address: / M 0 <br /> Cyt- <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 /> 1 Certification of Completed Vaccination 3 Contraindicated 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: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: 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 bod art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify a w1ledue and belief the statements made herein are true and correct. <br /> Signature: Date: /(� 0/ <br /> Print Name: Q. ( ✓j -" Z_.. Title: �} <br /> RFFId iJSE. LY . 777,7 <br /> 1,109 ra <br /> rnF" )� <br /> Fees. <br /> If 2 <br />