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San 3oaquin CoLin'til 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Enuirenraientall i-ilealth Departmen't -11,1: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILIT Y AND PRACT ITTOMER REGISTRATZOM/ <br /> CAECKANICAL STUD AND CLASP EAR PIERCING NOTIFWATIOM <br /> I.pR0C[.-:DUR[-:S TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing <br /> Mechanical Stud and Clasp Ear Piercing <br /> 10 P-1 <br /> ®Branding ®Permanent Cosmetics <br /> JZ.PEqUIRED PERMIT,OR NOTHH-KCA-1 IWA FEES:Check all that apply. <br /> !F-==IAnnual Body Art Practitioner Registration 3nmechanical Stud and Clasp Ear Piercing HotifiCatiOn <br /> L-1 <br /> 2MAnnual Body Art Facility.Permit <br /> Ill.A P P LIACA4T I N rO R14 A 71-0 N: <br /> %N P"), <br /> NAME: 6-� -E � a <br /> ±1�. O�G 1�k-\ � e(A-7 <br /> HOME ADDRESS: <br /> �1 Ike, I <br /> City: CD I State: Zi p: lq!=t sa <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: I 2-2- I Gender: M o-rjM (circle one) <br /> Identification Type: Drivers License Other Identincation No.: PO <br /> Facility vifhere Body Art Servires Will be Provided <br /> Facility Na 0� R Ovdner: <br /> Address: .912-`�;o lQfAGi-d�� C <br /> Evidence of Six-months of Related Experience <br /> Facility Name, 01A Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bleadborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis S Vaccination Status:Ciloose one and Submit Documentation <br /> 1MCertification of Completed Vaccination N%1A 3[=]Contraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4Mvaccination Declination <br /> V.FACILITY LOCAT IOM (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: 4- Suite: <br /> Location address: <br /> A c- L C1 e' <br /> State: Z-1 County: <br /> city: C� <br /> Owner/Contact: yot" ESH yfte�fL-..— Phone/Fax: 16- 3-�- <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: zip: CountV: <br /> Owner/Contact: Phone/Fay: <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 /> H Elereby cer'df�f'dqat t of m knovuriedge and betlef the staterrients MaI E B In are true and cuuvvecc. <br /> Pe lerc- <br /> Signature: Date: <br /> Print'Name: Title: <br /> FOR OFFICE USE OHLY <br /> Program (PE): Fees: Authorized by(REHS): _Date Entered: <br />