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• . San Joaquin County 1868 East Hazelton Avenue <br /> is z` Environmental Health Department StocktonCA 3220 <br /> p Tel: (209))468-3420 <br /> Fax: (209)464-0138 <br /> r 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) mtC rV E® <br /> Tattooing r7Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics Jul- 06 ZO12 <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. ENVIRONMENTAL HEALTH <br /> 1[:!j4nnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear PiercingR0MW1ACES <br /> 2[DAnnual Body Art Facility Permit <br /> NFORMAT ON: <br /> IIINAME APPLICANT:r-O `7CL i �`^ Phonel� 20 <br /> Y <br /> HOME ADDRESS: ��G rC'CIVi— Email: <br /> Cit C-t1 State: Zi S3 Count ck <br /> Date of Birth: L Gender: M or (circle one) <br /> Identification Type: MDrivers License Other Identification No.:.22 <br /> Facility where Body Art Services Will be Provided ' '/ <br /> FacilityName: �r- �C- '�3�S Owner: W G" <br /> Address: X21 <br /> Evidence of Six-months of Related Experienc <br /> Facilit Name: u � ��', Owner: Wo <br /> Address: `bZ� 1 1t ' <br /> Service You Provided: \ n <br /> Supervisor Name and Contact Information: c � ?� �2���� \'2- <br /> Bloodborne <br /> 2Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: 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 ctices governing mechanical stud and clasp ear piercing. <br /> I hereby certify t e y k ed nd belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: c Title: a�._ <br /> S c � <br /> f2 <br />