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f San Joaquin County0 CA <br /> 1868 East Hazelton Avenue <br /> i Environmental Health Department Tei: (209)4Stockton,4668--82203420 <br /> �,.. <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 /> [ZIT-attooing ®Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> ®Branding ®Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1®Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2Annual Body Art Facility Permit <br /> 111.APPLICANT INFORMATION: <br /> NAME: KGVIAI t-pft Phone: lay-& f f—qAr�j <br /> HOME ADDRESS: ��'/� SY/Va% AA ,r�;aT /Id7 Email: lAhlra6 <E, <br /> Ci ' State: Zi County: v® <br /> xBEfDIf`ARTPRAGTITIONER.:ONLY <br /> x a,.. 01"10TIANIM <br /> Date of Birth: ;Tf& V4Z Gender: F or PEPr(circle one) <br /> Identification Type: Drivers License =10ther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: O Owner: <br /> Address: 252S , LoZ <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®Cert1ficatlon of Completed Vaccination 3®Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4 FRIVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) , <br /> 1. BUSINESS NAME: ,EMS god a2k t LEL-c—lAll <br /> Location address: 2-57 IS -5r /� a Suite: <br /> City: LOD; State: CA Zip: f-57-5Q County' S <br /> Owner/Contact: _)Rg ' !� Phone,/Fax: X09 333� �Z <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 to the best o&my knowledge and belief the statements made herei are true and correct. <br /> Signature: Date: — <br /> Print Name: ,t/ Title: <br /> OR OFFICE USEONL �� f <br /> rogra ;(PB) Fees utho ized�l VaREHS) ti <br /> Date Entere <br /> a .', at °,., s.+�.�v *'?Y 'r, `.�; Rs,. mss, .... .'t�9r� .�+2a'.a 3....¢�,az :.. <br /> 16ef2 <br />