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San Joaquin County 1868 East Hazelton Avenue <br /> e95205 <br /> nvironmental Health Department Stockton)46 -3420 <br /> P Tel: (209)468-3420 <br /> e Fax: (209)464-0138 <br /> BODY A FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECH OAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFOD:Check all that apply (see back for definitions) <br /> Tattooing Body Piercing MMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,FFMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1©Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICANT <br /> CAN `FQRMATION:Aut `^ D phone:2-0 � v o </ 1�t <br /> HOME ADDRESS: pr `� I ' r 1 C/ �t Email: 0 7 cp VXo j 1-1vG1i�. <br /> City: lit) ` "state: "- Zip: \G Q- County: ANT atai.V10 <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: (� Gender: Mor MM (circle one) <br /> Identification Type: rivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided \ <br /> Facility Name: w I C)V Owner: <br /> Address: D w -,t <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne 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 3MContraindicated for Medical Reasons <br /> 2[:3Laboratory Evidence of Immunity 4[=Ivaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: \.Av <br /> Lo on address: Suite: <br /> Ci State: Zip'. U County: <br /> Owner/Contact rJli�/1 N 5�R �� 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 certitt that to the b st of my knowledge and belief the statements made herein Copre true and correct. <br /> Signature: Date: <br /> Print Name: \ /7uc 4 y\ . Title: <br /> FOR OFFICE USE ONLY �y �� <br /> Program (PE): 4q/� /p Fees: � Authorized by (RENS): ZALV � lw Date Entered: " <br /> %� f2 <br /> MW 141 1. <br />