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�i�?sE•. San Joaquin County 1868 East Hazelton Avenue <br /> 3 1 A 95205 <br /> Environmental Health Department Stockton3420 <br /> p Tel:(209))4468--3420 <br /> I - 6 <br /> Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDU TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing OMechanical Stud and Clasp Ear Piercing <br /> ®Branding ®Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i 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 /> NAME: Phone 20� SC1 — I <br /> HOME ADDRESS: 2 • lF Email: <br /> City: V-O State: Cok Zip: County: A <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Q p �((7 Gender: F o M circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: ") Owner: <br /> Address: �� t <br /> Evidence of Six-months of Relate"xperienqe <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: - 2 v G Training Provided by: LSAVW ®V\ 1 <br /> Hepatitis B vaccination Status:Choose One and Submit Documentation <br /> 1177n Certiflcation of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4®Vaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: rA� CJS <br /> Location address: Suite: <br /> Ci iL, State: Zi Coun C1 LA <br /> Owner Contact:\Jk 'C met 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 s fe body ctices or ctices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that a be knowle nd belief the statements made herein are trueandcorrect. <br /> Signature: Date: 71(op ®20i p <br /> Print Name: ov Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(REHS): Date Entered: <br /> __jf2 <br />