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San Joaquin County 1868 East Hazelton Avenue <br /> { <br /> Environmental Health Department Stockton)46 -3420 <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.PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing ®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 /> 1Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> NAME: Phoney 1700 <br /> HOME ADDRESS: Email: <br /> Cit State Zi Coun <br /> t>a'RAttTiT ONERwflN1Y <br /> Date of Birth: =6 IC41 Gen r: M or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body ArtS rvices Will be Provided <br /> Facility Name: Owner: <br /> Address: I �- <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 /> Certlflcatlon of Completed Vaccination 3®ContraIndicated for Medical Reasons <br /> 2_[[FDDi_La_bbratory Evidence of Immunity 4®Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: Pf � <br /> 19 <br /> Location address: W� Suite: <br /> Ci State Zi Count <br /> Ownerl Contact: Phone Fax: <br /> 2.BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: ZIP: !j County: ®4'�t _ <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 cern at to the best of my knowledge and belief the statemen de her in are true and correct, <br /> Signature: Date: <br /> Print Name: Title: <br /> OFFIC US ONL <br /> og <br /> . 5._. ... <br /> f2 <br />