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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> f 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 /> jEg3Tattooing ®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 /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> 1'.j _�® ! ® , <br /> NAME: 1 1`� 1 Vt S Phone: �i t� �r b 0 e -0 ®"7 <br /> HOME ADDRESS: 'J01 i)OD SSte'^ V-10 2 Email: <br /> City: CAG State: Zip: )6 County: <br /> V2 � sr w a <br /> AR-T „RACTITIONER'TOI�Tj. a,, . �J <br /> Date of Birth: Gender: F o ircle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 1/>v. SI pe-c VZOL IK ® Owner: eS <br /> Address: w f G C <br /> Evidence of Six-months <br /> .. I <br /> of Related Experience <br /> FacilityName: �+L I TOK O Owner: Lf /► .�G r <br /> Address: U 1 <br /> Service You Provided: <br /> Supervisor Name and Contact Information: V-"Ch <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Com feted: 7Z13 Training Provided b <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 10—Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary <br /> 1.BUSINESS NAME: Yti S?AA w� O <br /> Location address: a W5f� Suite: <br /> CI_ty: c w c� State: ( Zip: County: <br /> Owner/Co�6!2(2+s &E4-65 Phone/Fax: 5.. <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 to a est f my knowledge and belief the statements made herein are true and correct. <br /> Signature: - Date: <br /> Print Name: S Title: <br /> pxogra PFS �e A ho�xed b IZ1;t)S = Dade E�tefed xa ' <br /> f2 <br />