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--------- - ---- -- -------- - <br /> San 3oaquin County 1868 East Hazelton Avenue <br /> Stock-Lon,CA 95205 <br /> EnWronrinental Healtii Departme"t -lei: (209)468-3420 <br /> ax: (209)464-0138 <br /> BODY AR71 FACIL1 Y AMD PRACTITIONER REGESTRATOM/ <br /> HECH-ANICAL STUD AND CLASP EAR P9ERC1MG MOTIFICAT TEGH <br /> Z.PROCr--DURE,155 T 0 BE PERFORMED:Check all that apply(see back for definitions) <br /> EOTattooing M-2-Body Piercing MMechanical Stud and Clasp Ear Piercing <br /> ®Branding ®Permanent-Branding Perman®Permanent-Cosmetics <br /> H.REQUIRED REGISTRATION,PERMIT,OR NOT.-IFI-CA-110M FEES.Check all that apply. <br /> i[MAnnual Body Art Practitioner Registration T­Nechanical Stud and Clasp Ear Piercing Notification <br /> 2Annual Body Art Facility Permit <br /> HF.APPLWANT!NFORMATZON: <br /> NAME: J b V) Phone: <br /> HOMEADDRET: <br /> Gt Email: 3MAn.Lnhdepo r Q0.1 <br /> C k t2h t, <br /> City: State: County: CnL_tfj2, C05 fO, <br /> r <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 12511 _ojS (circle one) <br /> Identification Type: LoDrivers License 1Other Identification No.: <br /> Facility vAhare Body Art Services Will be Provided <br /> Facility Name: Lc4u S --- Owner: Do I <br /> Address: <br /> 3R Y) 1) -TV-rx C r n Ci 5 <br /> , � n I <br /> Evidence efSix enthsafis,elated Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact information: <br /> Bloodborne Patho n— .nin g:Submit certificata <br /> ra <br /> Date Completed: Z/-/ Training Provided by: <br /> Hepatitis B Vacc!i .tin, Status:C&-jaosL-®rhe and subrnit Documentat han <br /> 1[::ICertification of Completed Vaccination 3Mcontraindicated for Medical Reasons <br /> 2[MLaboratory Evidence of Immunity 4[Mvaccination Declination <br /> LV,FACILITY LOCAT 10M (S):(Attach additional sheet's as necessary) <br /> i. BUSINESS NAME: Lt)±U S 9(ta,I <br /> Location address: 3ZOL) r7.0 a Qjce- F-=1t(0 T-r-6 Suite: ICP <br /> City:MCCL CState: Zi a �z, 5 ft) Count <br /> an q53o <br /> 5 <br /> Owner/Contac qZ <br /> Phone/Fax: <br /> 2. BUSINESS MAME: <br /> Location address: Suite: <br /> City' State• Zip: County: <br /> Ownerl 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 /> est wd-- rLd bal ief the Statements M- ada 916 erre alae crew and ce5 t. <br /> Signature: Date: f C <br /> Print Name: Title: oie <br /> FOR OFFICE USE GHLY <br /> Program (PE): Fees: Authorized I by(RE I HS)- _Date Entered_:: <br /> f 2 <br />