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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 />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Battooing Body Piercing [Zlmechanical Stud and Clasp Ear Piercing <br />randing Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />irMAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2QAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION¢ <br />�Zi 1/1l. Aim& ADi A, <br />4Kribe- 4arlCoVrk0 i,%.Cc' <br />City: KkQ0NTNN 1 1" U Si= State:6A Zip: 15-3"111 County: SAtl� J060"i'd <br />N <br />Date of Birth: Gender: <br />F r M (circle one) <br />Identification Type: ImDrivers License MOther Identification No.: <br />2 / <br />Facility where Body Art Services Will be Provided <br />C7� Owner: UN <br />FacilityName: f2- MUNV-� YS 7A-uaJ <br />,\ <br />+404-CA/\jt ) <br />Address: (� ni . C t NTW - -6LV ID , TRACT-' CA <br />5--3-%(- <br />05--3-7(- <br />Evidence <br />Evidence of Six -months of Related Experience <br />Facili Name: �� �i-;N� Owner: <br />LSE Z i <br />Address: <br />Service You Provided: o)Y Aa -i- ITAt N lc-, <br />Supervisor Name and Contact Information: &A, C)� 9 i q-2-� <br />Bloodborne Pathogen Training: Submit Certificate ,moi <br />Date Com leted: l $ 7�l Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3 Contraindicated for Medical Reasons <br />2[DLaboratory Evidence of Immunity 4tE2Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: 12- Xti� Fi--ei5 r-A-rTc5D <br />N. C <br />�11 State: C -A Zip: 015-3--((- Coun : SAS J �� ' `A-) <br />Phnne/ Fax: Zo."1--) S,91 — I 2-�S7- <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 t o th s ledge and belief the statements made herein are true and correct. <br />Signature: e: D&// 3/--&/ T <br />Print Name: "-ASiPcL, i?C- (-A-PJ L 0 017-T Title: P -LIS % <br />