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• <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Awah. CA <br /> Environmental Health Department Stockton3220 <br /> P Tel; (209))4 4666--3420 <br /> W-1 , 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 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 /> 11MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> 1 <br /> III.APPLICANTHIFOR[j�4ATION: f \ <br /> NAME- V t r 1�(�,,j-VALk_/Vj ��2 Phone: 'D <br /> HOME ADDRESS l <br /> -�� �C L Vlk ����Ct Email: <br /> city: : n(_A' TW\ State: (Cc J Zip: (a 2- U County: <br /> BOD. AR%PRAC'TITIONE ONLY,, <br /> Date of Birth: Ci 1 9 Gender: M or M (circle one) <br /> Identification Type: MDrivers License r7lother Identification No.: V ` <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: -- C\ �(� Owner. <br /> Address: 1 Z CL u-'eul <br /> Evidence of Six-months of Related E erten <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[E[Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[:JLaboratory Evidence of Immunity 4[::]Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: 1 <br /> Location address: Z 1 t UV Ca Suite: <br /> City: - ate (j Zip: ) L 1� County: 5('�Vi 61/ <br /> Owner/Contact: Phone/Fax: <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 th i;to the best of my knowledge and belief the statements madehereinare true and correct. <br /> Signature: L�� �— Date: (; L/ [moo <br /> Print Name: `-( Li N Title: <br /> FO OFFICEUS�E ON 'Y ;.� •�, �. s '3� � � � r � `� �� <br /> Of 2 <br />