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v <br /> �� <br /> -r.46' <br /> �� 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 /> ,RAODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> AECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> EnTattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1�Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: \ <br /> NAME: `2kGA9-D0 AR-�C-NA. Phone: L7o7145e7-072`1 <br /> HOME ADDRESS: 19 S'4 M r 0 b t E F-1 r L-b pVi�__ Email: tu. C 0 A'2--T s P� 4D ya <br /> City: Ta G 'rte^j State: zip: y 2 o"I County: N <br /> Flo <br /> Date of Birth: E C- — Z I el -7 S Gender: M o M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: 0 3 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: N k_C- y _TZ TTDQ JT00J&ner: <br /> Address: L - a A Cq 3 7 tO <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 i <br /> Date Completed: FE Rj 1 1 Zv 12-Training Provided by: (% tA NL V ti( VC✓Q-s T <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2 Laboratory 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 practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that to the 1wt knowledge and belief the statements made here'n are true and correct. <br /> Signature: _ Date: -D / /Z <br /> Print Name: P-1 GA 1 p tT CA!ZD SNA S Title: TA'TTo O E re - <br /> If 2 <br />