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• r'' 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 ®Body Piercing OMechanical Stud and Clasp Ear Piercing <br /> ®Branding ®Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: I.-A G` Phone: <br /> <br /> <br /> Date of Birth: jl - zc-stGender: F or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Lt Owner: U7, e <br /> Address: ® 6147 Zp <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: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination. 3 Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4FZ71Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: L S t <br /> Location address: orAji02 Pel `4 J �r Suite: <br /> City: s4 State: Zip: f5- �f Count JVD- ujk.) <br /> Owner Contact: Li'_ Phone Fax: - 3_ <br /> 2. BUSINESS NAME: i k f C' <br /> Location address: X121 rad tri Suite: <br /> J <br /> City: G State: 04 Zip: County: v. <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 bes of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: V211 4Title: �� '(Z ., <br /> h�Y <br /> r <br /> f2 <br />