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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department StocktonCA, <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) 9ALZG;4�/�zll <br /> Tattooing 12Body Piercing Mmechanical Stud and Clasp Ear Piercing '/&z '0 Permanent Cosmetics <br /> / ZOlZ <br /> II. REQ-)Annuall Body Art Practitioner'OR RegNOatFonCATION FEES: <br /> ]Meehan cal Stud Check all that end Clasp Ear Piercing Noy. tii SRC 4�4w/y�� <br /> 21=Annual Body Art Facility Permit CN <br /> III.APPLICANT!NY 1 1INFORMATION- q 1 '7 C� <br /> NAME: A g f"e U Iq6d 61g 11 Phone: �1 / 33�—1 r ? ! <br /> HOME ADDRESS: 15 01 00.01Ce✓ w``� Email: <br /> City: 'TvyLo r✓!C State: Ld zip: County: <br /> Date of Birth: 1 - - NQS Gender: F o M (circle one) <br /> Identification Type: Mprivers License MOther Identification No.: J3 �( <br /> Facility where Body Art Services Will be Provided l <br /> Facility ")Name: �►Lk e"A' L-) k Y Z-- Owner: C Ur QQ �K T 1'0 h <br /> Address: 1-0 S . G * k e i L ki. L o 1` <br /> Evidence of Six-months of Related Experience <br /> Facility Name: 1n/i ( V-ed Gt Z- Owner: <br /> Address: 20 r0 k � <br /> 0-< Lti t,dr C <br /> Service You Provided: f3c>()r P,'e,-L,ocj <br /> Supervisor Name and Contact Information: G <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: L - 1 - i I-- Trainingp Provided b : f P409 Z X-r't-q S =,'1 C - <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1[0Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4[::]Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: -J1,c e d 1,) c-, y I— <br /> .e1 <br /> Location address: qTo c- r�k-A Lys . Suite: it <br /> City: L tea; State: C-41Zip: gSZ�lo County: 5lk To� tC���ti <br /> Owner/Contact: Wl ok h✓hta+t Phone/Fax: 33 y (7 / y <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 the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> C -'L, — I` <br /> Print Name: j,afn r,,�.,,� o9L.L�(k��, Title: P r'e5,'d en ?- <br /> f2 <br />