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1 7 <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Department Stockton,46 -3220 <br /> Environmental Health De <br /> P 7e1:(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 /> QTattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> iMAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICPIT INFORMATION, <br /> FL <br /> NAME: S Lt 0 i1 l>; G�� Phone: J[ <br /> HOME ADDRESS:30!� 1� P-01;\y gi Email: L12161G�►thy�C h l it�l��(� ��n��i� <br /> City' TJ�G-c-At C In State: C A Zip: C} S� � � County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 61 i.;2S j G .7 & Gender: F or MM (circle one) <br /> Identification Type: MDrivers License MOther Identification <br /> Facility where Body Art Services Will be Provided <br /> Facili Name: 4A Owner: . <br /> Address: <br /> t65 <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: c '11 lei Training Provided b : 1 fit1�t1 <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3OContraindicated for Medical Reasons <br /> 2QLaboratory evidence of Immunity 4ttivaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: TO[CS r �_ L <br /> Location address: S ( E Suite: <br /> Ci State: 'A" Zi Je County: "i< i,ij1 <br /> Owner Contact: � � �% rj <br /> Phone Fax: �1' s <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 thattoo�11the best of m knowledge and belief the statements ma/de herein are true and correct. <br /> Signature: '� ' Date: " / C C 1 n <br /> Print Name: l r Nli t t L1 Title: <br /> FOR OFFICE USE ONLY <br /> Pr' (PE): Fees. Authorized by(RENS): Date Entered. <br /> f2 <br />