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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton, CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> ECAICAL STUD AND CLASP EAR PIERCING NOTIFICATIO <br /> I. PROCEDU13ZS TO BE PERFORMED:Check all that apply (see back for definitions) <br /> attooing Body Piercing Mechanical Stud and Clasp Ear Pierci <br /> 7nr <br /> Branding Permanent Cosmetics V/ <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 An ual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notific atiq4 <br /> 2rZ77rAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: (� <br /> NAME: Phone: t' J <br /> HOME ADDR SS: �jL(� tNd�� �( J Email' yty!i}(� �i/ �� t �• <br /> City: tf QUA State: CA Zip: 1600 County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: V4 Ago Gender: F or M (circle one) <br /> Identification Type: rivers LicenseOther Identification No.: 011`j 3 39 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: i f ` j Owner: 1 <br /> Address: i-✓t. <TE C. 'CA 61 S20-7 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: pikck r Owner: ;VVkV% h-� i/ z <br /> Address: !A 4Nr 16+54 2 <br /> Service You Provided: TA + <br /> Supervisor Name and Contact Information: 4 UOV% 4 S L <br /> Bloodborne Pathogen Traini : Submit Certificate <br /> F�s <br /> Date Completed: Training Provided by: C "-pt' s <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Contraindicated 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: I eae- 14± <br /> Location address: !! tt IF Moira, ?4, Suite: <br /> City: State: CA Zip:4152ACI County: 5� V\ <br /> Owner/Contact: dnVi Phone/ Fax: Ito "7 <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 b st of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: (`S / til <br /> Print Name: Irot" A t AA Title: OV-041( <br /> FOR OFFICE USE ONLY <br /> Program (PE): / Fees: // Authorized by (RENS): ate Entered: S <br /> RM 127 1 1 f2 <br />