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k San Joaquin County 1868 East Hazelton Avenue <br /> Department Stockton,46 -3220 <br /> Environmental Health De <br /> P 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 ®Body Piercing ®Mechanical 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 /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: L Phone: ! <br /> <br /> <br /> Wa�ai <br /> Date of Birth: �t>r Gender: M or M" (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facilit Name: U gOwner: i� wl�eavwkv <br /> Address: <� ( C G <br /> Evidence of Six-months of Related Experience <br /> Facility Name: �glQHirla, G 0 Owner: Ml <br /> Address: 213-106tae <br /> Service You Provided: <br /> Supervisor Name and Contact Information: i <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: ' TraininQ Provided b Give /Gin P k? ® cdlkn <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 add'tion I sh et necessary) <br /> 1. BUSINESS NAME: S v v Alffeo <br /> Location addr s r vot Suite: <br /> city: State: Zi County: a! <br /> Owner Contact: l ��"/ Q,, h Fax: ` L' + 2 <br /> 2. BUSINESS NAME: <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 certifyt t to the. s f my kno Iedge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: ®f <br /> Y'�.� <br /> if 2 <br />