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San Joaquin County 1868 East Hazelton Avenue <br /> 46Stockton,CA 95205 <br /> t4)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 /> ramw [:3Mechanical Stud and Clasp Ear Piercing <br /> MdTattooing Body Piercing <br /> ®Branding EDPermanent Cosmetics <br /> 11.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> IMAnnuai Body Art Practitioner Registration 3[::]Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[:]Annual Body Art Facility Permit <br /> III.APPLICANT INFOltMATION: <br /> Phone: LJ <br /> NAME ] DD <br /> . <br /> <br /> <br /> BODY ART PRACTITIONER ONLY, <br /> Date of Birth: Gender: M or M circle one <br /> Identification Type: EnDrivers License Other identification No.: <br /> Facility where Body Art Services Will be Provided <br /> E0&ft0wneq_& <br /> Facility Name: all-I LULL <br /> Address: Z.3 <br /> Evidence of Six-months of Related Experience <br /> A <br /> k <br /> Facilltv Name: Oct Pllt(JOwner: <br /> Address: D <br /> Service You Provided: j'+ <br /> Suvervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: 12-I- /:?- Traininq_trovicled§j: <br /> Hepatitis 8 Vaccination Status:Choose One and Submit Documentation <br /> 1[:3Certification of Completed Vaccination 3[:]Contraindicated for Medical Reasons <br /> 2[:3Laboratory Evidence of Immunity 425Vaccination Declination <br /> IV.FACILITY LOCATION(S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAAUC. <br /> 11R1 _i1F_- <br /> Location address: 'Z-75 LE <r Suite: <br /> qb�: T dL County: 501-At qm'7 <br /> LACA1 State: Mone Z I P: 111 <br /> Owner/ContactfAMANrit Fax: <br /> 2.BUSINESS NAME: <br /> Location address: Suite: <br /> agj: 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 best of kno 4 I!e;pd e statements made herein are true and correct. <br /> 'fiW i, <br /> Date: <br /> Signature: <br /> Print Name: & Tide: <br /> FOR <br /> FOR OFFICE USE ONLY <br /> Program <br /> Program(PE): LJ110 Fees: _LS� _,_, Authorized by(REHS): Q4 � "ate Entered. <br /> V Nu 1 1 —12 <br />