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1868 East Hazelton Avenue <br /> San Joaquin County <br /> environmental Health Department el:Sto(209)kton,CA -3220 <br /> P Tel: (209}468-3420 <br /> '-1.1 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 /> aTattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> F—IBranding ff Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1r7jAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLIC NT INFO ATI N: LU <br /> NAME: /TiPhone: — `'1 <br /> 32— <br /> HOME ADDRESS: 5 - —b 1 �1 ait: NtyDl� <br /> Ci State: Zip: 1 County'. �d <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 12 "35 Gender: F or MM (circle one) <br /> Identification TVDe: IV716rivers License MOther Identification No.: <br /> Facility where Bod Art Services Will be Provided <br /> Facility Name: 1 Owner: <br /> Address: U! - <br /> Evidence of Si mo`n/ths�ofRelated Experience /y _ <br /> Facilit Name: 1 V 1 11. /y Owner: Vl <br /> Address: W <br /> Service You Provided: <br /> Supervisor Name and Contact Information: S IDQW12 5 <br /> Bloodborne Pathogen Trai 'ng: Submit Certificate <br /> Date Completed: ` Trainin Provided b <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[:DLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> U� Ib x-1'1 fir. �— <br /> location address: ._ //--__Suite: <br /> Ci : p State: Zip: U6oun : �( Y1 <br /> Owner Contact K C� z Phone Fax: IL4D -1 2 <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner Contact: Phone Fax: <br /> The undersigned hereby appl' f r a ody Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud and Ear Piercing Notific ti and ees to operate in accordance with all applicable state and local <br /> requirements Qvverning safe b art a tices or practices_governing mechanical stud and clasp ear piercing. <br /> I hereby cern h b n n b Iii f the statements made herein are true and correct. <br /> Signature: Date: . ' 1;7 1 1 '1 <br /> Print Name: Title: mlweu <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> If2 <br />