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- . San 7oaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> Tel:(209)468-3420 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ Fax:(209)464-0138 <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I.PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing dy Piercing oMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.REQUIR D REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1nnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2MAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATIO <br /> NAME• Phone: <br /> HOME ADDRESS: Email: VC6 ( -, <br /> city State: C kZi 0 county, <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: or MM (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: �� <br /> -I�Iukl6lrjl-A 4L-- <br /> Address: J <br /> Evidence of Six-months of Related Experience <br /> Facility Name: <br /> Owner: ChfiA <br /> Address: <br /> Gov <br /> Service You Provided: <br /> Supervisor Name and Contact Information: �� <br /> Bloodborne Pathogen raining:Submit Certificate <br /> Date Completed:_ Training Provided b <br /> Hepatitis B Vaccination Status.Choose One and Submit Documentatio <br /> 1ECertification of Completed Vaccination 30Co raindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4 accination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: <br /> Location address: Suite: <br /> Cit State: Zi county: <br /> -Owner/Cont ct• 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,t t o t of my knowledge and belief the statements m de herein are true and correct. <br /> Signature: Date: -- ,(,� '�-A 0-\ <br /> Print Name: SIE Title: r_ <br /> FOR OFFICE USE ONLY <br /> Program(PE): Jill () Fees:f j S; Authorized by(REHS): q8346 Date Entered: t la? <br /> If2 <br />