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f <br />Safi .7Oaquitl Counter <br />1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />` <br />'> <br />Environmental Health Department <br />Tel: <br />' -� "V <br />(209) 468-3420 <br />Fax: (209) 464-0138 <br />I. PROCED RES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing ElBody 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: - lckV % tT N v VtV yk (. q G1'� Phone: 2®" 'w (- �n <br />l Z <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: ®� \ b Gender: F or (circle one) <br />Identification Type: Drivers License =Other Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: Sk%A ®QV\ % NOU Q tCY ,va Owner: %IiAVVi ®\Ackv0 6) <br />Address: day 5 "SVGA` C, <br />Evidence of Six -months of Related Experience <br />Facility Name: 4 Mke®\/\ \ Owner: �)Mln\np <br />Address: SG CX Or "Ok r0" 3 "1 <br />Service You Provided: i � \ L <br />Supervisor Name and Contact Information: 0 via <br />Bloodborne Pathogen Training- Submit Certificate t\ ® V 93 • C® rM <br />Date Completed: (k " ZOI � Training Provided by: Ce, \_, UYY1tq 691'0GrV%'C Qq�t�OgCvcti <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1 Certification 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: g7kL\R O()NA �O'N\00 Iktv(atn <br />Location address: Cl) - Suite: <br />City: '�YAc®' State: t 1`r Zip: �lS3®16 County: <br />Owner/ Contact: -LO- 0Phone/ Fax: <br />2. BUSINESS NAM <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 t at the bestWkw <br />wledge and belief the statements mad�ej herein a(r'e� true and correct. <br />Signature: Date: <br />Print Name:U y e i i X vet\ { A( a at Title: <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (REHS): Date Entered: <br />