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San Joaquin County <br /> 1868 East Hazelton Avenue <br /> Sto <br /> l dpi r1 Environmental Health Department el: (209)46kton,CA -3220 <br /> p 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. PROCED ES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing r7Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding QPermanent Cosmetics <br /> II.REQUIR30 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 /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICARINF012MATIOjMI: ) � . <br /> NAME: C, 2'fl r t c.-X")/e L 1 Phone: <br /> HOMEADDRESS: [ l� -'l r Email: <br /> Cit Y State: <br /> Zip: Aj�G�i County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: (�— "� Gender: M or r7o (circle one) <br /> Identification Type: r7lDrivers License Other Identification No.: <br /> Facility where Body Art Service Will be Provided 1 / <br /> Facili Name: �% ` �C Owner: <v!� h <br /> Address: v, < -� J <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Su ervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate // <br /> Date Completed: TrainingProvided by: �c t {!�L4 - <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertificatlon of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4�/accination Declination <br /> IV.FACILITY LOCATION(S):(Attach additio al heets as ne/(5SesJ�ary) <br /> 1. BUSINESS NAME: 4 [ cr r> <br /> Location address: Z-5 L,S 0Suite: S t� <br /> City: State: Zip: county: 5 �? f��✓� <br /> Owner/Contact: t !I vc��t > f/i .-%`/� Jf[P ne/Fax: ?_,C> --?q 0 <br /> v <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 th b t of y kno edge and belief the statements made herein are true and correct. <br /> Signature: Date: J Z 0 <br /> Print Name: -, s Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(REHS): Date Entered: <br /> If2 <br />