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4' San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Q00g." <br /> Environmental Health Department Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> 'MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION RE C E Al <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing MBody Piercing F7mechanical Stud and Clasp Ear Piercing J C .17 1012 <br /> Branding Permanent Cosmetics <br /> nnnAn01aar14rX HEALTH <br /> II.REQU RED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. PERMIT/SERVICES <br /> i Annual 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: S5r-A n Phone: 02 -<�+3 Z) <br /> HOME ADDRESS: S 1 A 4---k^de t Email: <br /> Ci alf4 - State: A Zi County: —C;p Pk O <br /> 47,- <br /> .P.4 <br /> r -,F rt ,Ys r' 'x; _-, x,-BODY ART PRACTITIONER ONLY <br /> Date of Birth: 4&2 Gender: M or "M (circle one) <br /> Identification Type: 5ZIDrivers License MOther Identification No.: ,?0 73 <br /> Facility where Body Art Servic s Will be Provided <br /> FacilityName: f Owner: n At, PC Ile-e- <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: -e bA Owner: nPere- \I <br /> Address: <br /> Service You Provided: Ce <br /> Su ervisor Name and Contact Information: O 1 fl — r <br /> Bloodborne Pathoge Training: Submit Certificate ) <br /> Date completed: ®2 'y Trainin Provided b : o t/" <br /> He pa itis B Vaccination Status: Choose One and Submit Documentation <br /> Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: h Suite: A, <br /> Cit State: A Zip: County: G-A Vj Jv <br /> Owner/Contact: Q rMr 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 tha o the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: 'e- -X" Date: (0 it g 1/20/2 <br /> PrintName: A Title: 6 j. <br /> FOR OFFICE USE, 1. <br /> Program (PE) ees Authorized by(RENS) Date Entered 6�. . <br /> -muv_ - _ f2 <br />