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•' San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> j <br /> Environmental Health Department 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. PROCEDUI;Vd% <br /> BE PERFORMED:Check all that apply(see back for definitions) <br /> PCEIVED <br /> BodyPiercing Mmechanical Stud and Clasp Ear Pierce <br /> 'Branding ®Permanent Cosmetics JUN 2 8 2f j <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1�nnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Pier i F1 1 <br /> 2©Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: L hNE5rwE- LUKE Phone: 01�y' cj/J ld (��� <br /> HOME ADDRESS: 17C W�r S�+%2GvYLGL- Email: <br /> City: Sd�R (�yl State: C� Zip: 0County: <br /> Date of Birth: Gender: F or M (circle one) <br /> Identification Typ Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> FacilityName: G � Gam'v► e Jc /oY) Owner: ct U `S <br /> / <br /> Address: R�7'13 &C` b G L lye, S G �I A" <br /> Evidence of Six-months of Related Experience <br /> Facility Name: /d hS ? Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate y— �^ <br /> Date Completed: TrainingProvided by: 4 e- t'/�rSr <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation 'yJe�y`C� /�Pa2hT �55d� <br /> 1QCertification of Completed Vaccination /vTone_ 3Mcontraindicated for Medical Reasons <br /> gone 13 /a <br /> 2MLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) , �E 1-,wa-,"te <br /> 1. BUSINESS NAME: Cl. c� � _!S; <br /> r:7 <br /> Location address: q3'1-3 pit di'T,`C: are_ Suite: X <br /> City: 6cKlo✓L State: C� Zip: 75-.2-0 7 county: S. J. <br /> Owner/Contact: 13t-&c/5/ o-yi 5 Phone/Fax: 4 6 <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,of my knowledge and belief the statements made herein are true and correct. <br /> 4 i /y� <br /> Signature: / �� "� Date: <br /> Print Name: �EAhe_S7`.,'h e_ L. U K E Title: <br /> O <br /> nuv 14111 mmnm <br /> 1f2 <br /> ri-IW I� <br />