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> a �p`�` <br /> San Joaquin County $68 'ast azelt nvn e "� <br /> Environmental Health Department Stockton,CA 3220 <br /> P Tel: (209)468--3420 <br /> Fax: (209)464-0138 h <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ 7 ?7G.C�c�zL./ ''C <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION i-ozS ' j rsvty� <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> �attooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> ] Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2MAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: _ © <br /> NAME: b I 7V N S M - C S�LtP\N 7I~ Phone: Zd V 1 -7 15 -7 <br /> HOME ADDRESS: 2 I -E L//V C T Email: <br /> City: State: Crp Zip: % r'�_G County: Sft /V J O f}(,ti /r\) <br /> I . , r. BOD A M RAeTITI0NERONLY ., r'r, <br /> Date of Birth: G /'7 Gender: M or M (circle one) <br /> Identification Type: rivers License Other Identification No.: 5 28 2- <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: L./14T _MA/N T74 7-7-00 Owner: <br /> Address: 72 PACIFIC N(vE 57-vG14"/V f q S�Z0 -7 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: /'N/ `2- Sk/N TA`T-rd 0 Owner: PH/L V145 UC-L <br /> Address:'Z"738 P/9L/F/L Avg 7S`Zd� <br /> Service You Provided: /} D <br /> Supervisor Name and Contact Information: PHI(- VASGI VfZ — 92-7 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 3 rd 0 S Training Provided by: CH"rI+y IMOIV TI Crs 130DIE Agjrfi�aHrNl 6 <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 r__j Certification of Completed Vaccination 3r--IContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4t2!jb'9ccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: CAST V1A/iV IW'r-TOO <br /> Location address: 7 17-2 PActfiC /RV Suite: <br /> City: STO cKTDN State: e-.4q zip: County: 9tAN JOAt�t�/N <br /> Owner/Contact: M Phone/Fax: <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: c2.o-�' Date: <br /> Print Name: t--5 Title: <br /> 1.,-" <br /> R OFFICEUSE ONLY 1, sir <br /> ProgramE) ees Aut o rze (RENS Dat En erect: <br /> Sw <br /> .vse v ..'� „�.` �ate 'dx. :'# '' ""�. :, .Na '.r� f .�dt• ,�^ ..Yt t?A3,.�-., 0';'" It, <br /> if 2 <br />