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San Joaquin County . 1868 East Hazelton Avenue <br />ckton, CA 95205 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. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing 1:18ody Piercing MMechanical 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[DMechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: % d /�� '331-&50q <br />/ ) 2� <br />NAME: fT i1 UI r 2� V I I I/ 1 �/ Phone: Z o'7 73 t-& J 0 q <br />HOME ADDRESS-. 11 I$ S trot f_ C -o r C I r, /4 Pf 8- Email: dl r.e W V; o -'f "! i j G� C'0'o. C V'0'1 <br />e <br />City: J�Ct<"ibyi State: ct+ Zip: q'152O County: LM/kd sou S <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 2 2 i' Q 19- Gend : F or M (circle one) <br />Identification Type: ImDrivers License MOther Identification No. <br />Facility where Body Art Services Will be Provided <br />FacilityName: S n e If`•' i m! GL°S ` fA 4p s+uV to O er: -er- (Ca <br />Address: L W• q w w -e ✓ cm-4zr G d +-o 1 <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 Certificat L. <br />Date Completed: Z Z 12 Traini ded by: Ce' + -A YNo ✓� fl'� <br />Hepatitis B Vaccination Status: Choose n mit Documentation <br />19Certification of Completed Vaccinati 3MContraindicated for Medical Reasons <br />2 Laboratory Evidence of Immunity 4MVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach <br />�� ad( <br />1. BUSINESS NAME: s vK o k_, i/1 <br />E: <br />Location <br />[A <br />crico <br />is as necessary) <br />_r a, f+Db Sd(� <br />.e,v I otn e - <br />State: Chi . ZiD: <br />Suite: '% <br />S2a� County: [/N /1 <br />o 373-- 017 Ys' <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 +e best o y knov gledge and belief the statements made herein are true and correct. <br />Signature: X Date: 312, <br />3 1 2 - <br />Print Name: i'Cw / Title: C <br />5*4 �-e S <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (RENS): Date Entered: <br />f <br />F1+o0 aJDK <br />