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I <br />Aug. 29. 2013 11:21AM <br />r 4 <br />R e c e <br />Tib WORKNET <br />No, 5384 P, 1 <br />San Joaquin County 1868 East Hazelton Avenue <br />5205 <br />Environmental Health Department Brockton, CA Tel; (209) 468-3420-3420 <br />Fax: (209) 464-0138 <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />®Tattooing MBody PiercingMechanical Stud and Clasp Ear Piercing <br />®Branding MPermanent 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 />111. APPLICANT INFORMATION: <br />NAME; J h o'^ fDav;' Phone: cl r s 3yo c i? o <br /> <br /> <br /> <br />.u::1X R1# ... ; <br />IV. FACILITY LOCATION (S); (Attach additional sheets as necessary) <br />_ r <br />Cit r State: CA z12; -7 It. County: <br />Owner/ Contact: -1 berk t, l�e�l-wed' Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address; Suite: <br />City: State: zi : Count <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 the "V-knawledge and belief the statements made herein are true•and correct. <br />e <br />Signature: Date: g - a - l3 <br />Print Name: ���),,,,� pc,.>;s 7 _ Title: (D;erra�c <br />&.05CC�111te1�lR`X:: ••. ^. ... .. _::-:•rr.. <br />Date of Birth: Q(s r l$ 1 <br />Gender; F or rMT (circle one) <br />tdentiflcatlon Type; Drivers License =Other IdentlFlcatlon <br />Facility where Body Art Services Will be Provided <br />Facility Name: 14IIg,.t. :.,q <br />Owner; IbIZLIBct <br />Address: 3So , �< 5 F <br />e <br />(Evidence of Six -months of Related Experience <br />Facili Name: a <br />N u & - <br />Address: 00?_ <br />3131S_ <br />Service You Provided: 6e Ld <br />Super -visor Name and Contact Information: Soti,r� <br />1 f 2 ' Z 3Eo '7 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: u g -Z 1--)-3 Trainin Provided by: o . S t"_--3 <br />Hepatitis B Vaccination Status: Choose one and Submit Documentation <br />1 Certification of Completed Vaccination 3 Contralndicated for Medical Reasons <br />2 Laboratory Evidence of Immunity 4ER114accinatloin Declination <br />IV. FACILITY LOCATION (S); (Attach additional sheets as necessary) <br />_ r <br />Cit r State: CA z12; -7 It. County: <br />Owner/ Contact: -1 berk t, l�e�l-wed' Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address; Suite: <br />City: State: zi : Count <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 the "V-knawledge and belief the statements made herein are true•and correct. <br />e <br />Signature: Date: g - a - l3 <br />Print Name: ���),,,,� pc,.>;s 7 _ Title: (D;erra�c <br />