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• i <br /> San Joaquin County 1868 East Hazelton Avenue <br /> I A 95205 <br /> Environmental Health Department Stockton,Tel:(209)468-3420 6 <br /> Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> 1.PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> QBranding ✓ Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 v Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2OAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: L <br /> NAME: 4-i2earckC) A- Phone <br /> HOME ADDRESS: �,gq,2,5 cAllP Email: G�o��v�c.ZLiZc�r�a C�.G�-f�w,( •C,�kvt <br /> Ci State: Zi X70 County: A e-(' <br /> - <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: M or M (circle one) <br /> Identification Type: Drivers License Mother Identification No.: 11�34 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name::` �'� �£'-(, �^ Owner: <br /> Address: i�J� L t. •e Swlf -8 <br /> Evidence of Six-months of Related Experience <br /> Facilit Name: ei (,�t£+h TAg - Owner: <br /> Address: 'i s� 1'G tT�' CA q5- <br /> ✓� <br /> Service You Provided: ,►ll • -r <br /> Supervisor Name and Contact Information: �4/ k) <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Com leted: Trainina Provided by: AAnfth-e <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> I M Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[—]Laboratory Evidence of Immunity 4faccination Declination <br /> IV.FACILITY LOCATION(S):(Attach <br /> V( <br /> taach-a�ddditional sheets as necessary) <br /> 1 BUSINESS NAME: Are-&-'vt - .Ssi'► Tin - <br /> � <br /> Location address: � �1j <br /> 4.1�4C Suite: I <br /> City: �'i State: Ga�Zip: -1S6-1-0C1 County: V d Y1 <br /> Owner Contact: AAlr l Phone Fax: 5- <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 tha to the b st of y knowledge and belief the statements made herein are true and correct. <br /> Signature: `&--X 1.1 Date: 2 <br /> Print Name: L7-Ad-Al) Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): 941 1C) Fees: 15,, Authorized by(RENS): 98 G Date Entered: <br /> 112 <br />