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... ........ <br /> ------- ---------- --- ----- <br /> ---- - -- ------- <br /> San 3oaquin Counliq 1863 East Hazelton Avenue <br /> Stockton, <br /> CA 95205 <br /> Et-ruirrim", entall Heaftcl DepartmelvTel: (209)468-3420 <br /> Fax: (209)464-0133 <br /> BODY ART FACILETYAND PRACTITIOMER REGISTRATROM/ <br /> MECHAMECAL STUD AND CLASP EAR PIERCIMG MOTIFICA71 ROM <br /> pRocE-:DUREs TO ER PERFORMED:Check all that apply(see back for definitions) <br /> F-1 <br /> [Mattoolng IL <br /> _ABody Piercing r=="Mechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent A <br /> --bermanent Cosmetics <br /> U.REQUIRED REGIS-i RATION,PERMIT,OR NOT-WK-CAT 10M FE-ES:Check all that apply. <br /> 1132fAnnual Body Art Practitioner Registration A=­li0-1Mechanical Stud and Clasp Ear Piercing NotificatlOn <br /> 2MAnnual Body Art Facility Permit <br /> I OM: <br /> III:APPLICANT IN FORMAT- <br /> C4 <br /> Phnne-. -�? n <br /> NAME: (Cs (2�� Phone: <br /> <br /> <br /> <br /> <br /> Date,ofiBirth: Gender: =F or EMT (circle one) <br /> Identification Type: Rhrivers License <br /> Facility irvilhere Body Art Services Will be Proulded <br /> Facility Name: e ck,5 WCAin 4-CA*JCIOwner: Ajoa-eA UG rx Cie <br /> Address: -2( /05 nV <br /> Via <br /> Evidence of Six-months of Related Experience <br /> Facility Name: CLC r <br /> Owner: <br /> Address: C <br /> Service You Provided: <br /> 'act information: E-1/4- 0 <br /> Supervisor Name and Contact <br /> Bloodborne Pathogen Training:Sub"'it Cc-rNficate <br /> Date Completed: LIL1711S Training Provided by: Buts C(I c-ki <br /> p -F-nit Documen n <br /> ,cpatitis B Vaccination StatLrs:Cilooss one and SuL ta 10 <br /> 1MCertification of Completed Vaccination 3MContrainclicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4acclnation Declination <br /> KV.FACILITY LOCAW IOM (S):(Attach additional sheets as necessary) <br /> 1-. BUSINESS M A M E: LO—Ct S 2' Z22--11�—1- 91", ;6 c,C <br /> Location address: Suite: <br /> e- <br /> City: State: zip: 0-52 05 County: 5�414V <br /> Owner/Contact: "Va Phone/Fax: -61 0(6 <br /> 2. BUSINESS MAME:'V <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 /> 7-t-,ererxf certi the statement-2 made herain. are trt-qe and ceh-vac . <br /> Signature: Date: <br /> Print Name: Title: <br /> L:oR Or-FICH USEE ONLY <br /> Pro'gr6m, (PE): [Fees: Authorized by(RENS): Date Entered: <br /> T <br /> F—W —4 <br />