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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />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) RECEIVED <br />'Tattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br />OBranding E3 Permanent Cosmetics JUL 2 2012 <br />I1. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. ENVI• N AL HEALTH <br />1CMAnnual Body Art Practitioner Registration 3�Mechanical Stud and Clasp Ear Piercing I WiRVICES <br />2[DAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: ��//��ryry U / <br />T\ l n Phnna /I J`(• � �i��� <br />HOME ADDRESS (I L45 N. Email: <br />r;r"•-f.�-.(f �D11 State: /-A zip: C75 00 County <br />„ r, BODY ART PRACTITIONER ONLY <br />Date of Birth: 3 %ci Gender: M or([M (circle one) <br />Identification Type: MDrivers License Other Identification No.: ro %S/ <br />Facility where Body Art Services Will <br />t.b�e�Provided <br />FacilityName: C -,-"l /1Q's �u7`r'cz Owner: <br />Address: _�O 1 �✓• C✓`d i. °` 6( �c'O <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: l �Z Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />IMCertification of Completed Vaccination 3[::]Contraindicated for Medical Reasons <br />2[:]Laboratory Evidence of Immunity 4[Z]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 practices governing mechanical stud and clasp ear piercing. <br />I hereby certify th t to th est of y knowledge and belief the statements made herein are true and correct. <br />Signature: Date: l l <br />Print Name: D04;& Trap Title: <br />FOR OFFICE USE ONLY b dal 1 <br />Program (PE): Fees: Authorized by (REHS): Date Entered: <br />