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M1 <br /> San Joaquin County ® 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton -3220 <br /> Tel: (209))44686 -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) <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> EDBranding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 nnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: en Phone 2'0 ,5 <br /> HOME ADDRESS: Email: r sp <br /> Cit State: Zi Count <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: F or (circle one) <br /> Identification Type: ID Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: S1"bc T®lv -r OD comimpy Owner: 4naje <br /> Address: 7qZ t 6P_ 4 V <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: — Trainina Provided b : s sR <br /> Hepatitis B Vaccination Status: Choose One and Submit Documenton <br /> 1 Certification of Completed Vaccination 3 C raindicated 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:S [` n! jTjpL2 CO2WA <br /> Location address: f. Suite: <br /> Cit State: CA Zi County: <br /> Owner/ Contact: Q Phone/ Fax: q) '-1111' <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 tha to�the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: / Title: (> <br /> FOR OFFICE USE ONLY <br /> Program (PE): Ll no Fees: j Authorized by (REHS): Date Entered: <br /> If2 <br />