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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 /> [:]Tattooing [—]B(,)Py Piercing Omechanical Stud and Clasp Ear Piercing <br /> [:]Branding Erermanent Cosmetics <br /> 11.REQUI REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 7Annual Body Art Practitioner Registration 3[_]Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[_]Annual Body Art Facility Permit <br /> 111.APPLICANT INFORMATION: <br /> NAME: 0 o YoL z Phone: Ll 0—135X' <br /> HOME ADDRESS. <br /> City: rf.Y_f :6 in.4 State: zip: !a:5W9'7 County: <br /> �DateofBl� or MM (circle one <br /> Identification Type:' [2Drivers License MOther Identification No.: N T5,7 f <br /> Facility where Body Art Services VAII be Provided <br /> Facllitv Name: 'A�4v_b_ VA Owner: ao <br /> (IgL <br /> ,_ qL <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: 411ffio� lik�h r4q1L . Owner:I III a <br /> Address; Pal'W-Vita <br /> Service You Provided: 410 0414LC &ULJ�_eup <br /> Supervisor Name and ContactInformation: akv'� <br /> Bloodborne Pathogen Training:Submit Certificate <br /> ' <br /> "� /I-U]14 <br /> Date Completed: Training Provided by: <br /> Hepatitis 8 Vaccination Status:Choose One and Submit Documentation <br /> 1[Z]Certification of Completed Vaccination 3[:]Contraindicated for Medical Reasons <br /> 2[_]Laboratory Evidence of Immunity 4ffKaccinatlon Declination <br /> IV.FACILITY LOCATION(S).,(Attach additional sheets as necessa ) <br /> 1.BUSINESS NAME: Uldi _TM- <br /> Location address: lclSuite: A <br /> -40 ' <br /> Citv: State: P'A Zip: Coun ty MAO ikn' <br /> OwnerR 1buieK 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 best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: cc6t&� Date: ZZ 7-C� <br /> Print Name: Q 1-2 L—Z Lt Title: <br /> 2 <br />