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-0 <br /> wsrf, San 3oaquin Countij 1868 East Hazel' n Avenue <br /> Stockton,CA 95205 <br /> Lffleilt Tel: (209)468-3420 <br /> El a ental Health DePail <br /> Fax: (209)464-0138 <br /> BODY ART FACILE–BY AND PRACTITIOMER REGISTRATION/ <br /> [AECHANICAL SIR <br /> FUAND D CLASP EAR PIERCING MOTIFICATIZO91 <br /> 7.PROCEDURES TO BE PERFORMED:Check ail that apply(see back for definitions) <br /> EnTattooing M—Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> ®Branding ®Permanent Cosmetics <br /> 11.REQUZRE®Rr--GjSTRATION,PERMIT,OR NOTIFICATION FEES.,Check all that apply. <br /> 1WAnnual Body Art Practitioner Registration 3 —' Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> RIF.APPLICANT INFORMATION: Phone: <br /> NAME: 0 Cr)q 5-41 60 .3 2 <br /> :[ �VA 6 <br /> JAW-aA- Cj <br /> HOME ADDRESS: 1-711 kft <br /> Gttiv- Email: . <br /> Ci State: Zi C <br /> BODY ART.PRACTITIONER ONLY <br /> Date of Birth: 12-/2- Gender: MF orMM (circle one) <br /> —44 — <br /> Identification Type: _ <br /> jDrivers License Mother Identification 2 <br /> Facility where lead iLAr'.Services Will br-2rovilded <br /> Facility Name: t or:54,12M 7A&O-V Ow r: <br /> Address: 1-3 1 G 36- W--vVh1Lt4j,2 j, 9 8 – - 1 4 <br /> Ec-L'denof Six-manths of Related Experl.s. <br /> Fac - <br /> ocEl <br /> . %V' <br /> Tame: Owner: <br /> d d reN: <br /> Serv4\u Provided: <br /> Su2(r1l—r\—e and Contact Information: <br /> Bloodborne Path n i ing:Submit Certificate <br /> Date Completed 77 0S 15 W <br /> I raining Provided by: C41 -q MWT146 6981 68T FA?-*-ij <br /> Hepatitis S Vaccination Status:Choose One and Submit Documentation <br /> 1[Z3Certification of Completed Vaccination 3Mcontrafndicated for Medical I Reasons <br /> 2MLaboratory Evidence of Immunity 4Eaccination Declination <br /> 3A <br /> IV.FACILITY LOCATION (S):(Attach additional 5beets as necessary) <br /> 1.BUSINESS NAME: F0 rlgMl <br /> Location address: G?2 14\4J! Suite: <br /> CiState: Zip: 4;12 31 County: 2�j�0(6& but" <br /> ty: �orye <br /> Owner/Contact: Phone/Fax: '706.1 <br /> 2. BUSINESS NAME, 9 <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 sale body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I[-iereby certtifif•ih-•`•to the best o"ry knovirledge and belle?the statements macle her in are true and correct. <br /> Signature: Date: ol 171 <br /> Print Name: 44,C- Title: tl*V-C4— <br /> FOIA <br /> OR OFFICE USE ONLY <br /> Program(PE): <br /> Authorized by(REHS): Date Entered: <br /> f2 <br />