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_ ------------ .....f.-. ------ ------ - <br /> V • San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tei: (209)468-3420 <br /> ,rj 4, )012 <br /> Fax: (209)464-0138 <br /> �E <br /> 7 C BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> pp pppNMENTALHEALTN CHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> FwRO <br /> I. PR� KII- S TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing [:38ody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES;Check all that apply. <br /> 1[EgAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2�(�nnual Body Art Facility Permit <br /> ]III.APPLICANT INFORMATION: <br /> NAME: �Nr_ Phone: 70q—S 3 z S Z <br /> HOME ADDRESS: WA L Email: " Ian OOtC otkA <br /> City::16AAk State: (_'A zip_: County: l <br /> BODY ART PRACTITIONERONLY <br /> Date of Birth: Gender: M o M (circle one) <br /> Identification Type: MDrivers License MOther Identification No.: gO0 Z3 <br /> Facility where Body Art Services Will be Ppovided eS <br /> Facility Name: EMeMk '1q++00 <br /> -+vO � ?t C'VXOwner: <br /> Address: LSZE 5. \\1A S-�- A# 8 L"A' Ca 17se C/0 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: ft $ t Owner: <br /> Address: , , It 8 Lad i CO- <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: 2 Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated 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:CnAMing&W C'S?,&_&CIna <br /> Location address: 257—YS_ y ih5 ,3 &d. CCi `9 zqL Suite: <br /> City: LvC�, T,. \ _- State: ��` Zip: 917-1q <br /> V County: sao, <br /> 7 <br /> Owner/Contact: 10a r � � Phone/Fax: Zpg-32.5-5-aZa� <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 certifyt t the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: ..c Date: <br /> Print Name: 'rpG,� � Title: <br /> FOR OFFICE USE ONLY f <br /> Program (PE): Fees: Authorized by(RENS): Date Entered: l" <br /> if2 <br />