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San Joaquin County 1868 East Hazelton Avenue <br /> z,. <br /> Environmental Health Department Stockton, 3220 <br /> 46 <br /> 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: heck all that apply (see back for definitions) <br /> ®Tattooing 5ffBody Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> ®Branding EDPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: 1 _ <br /> NAME: ick ra Czq q Y"\`''� i�� Phone: Q 0 q S3_7 (V2 0 <br /> _ <br /> <br /> BODY ART;PRACTITIONER'ONLY <br /> Date of Birth: o �Q cl q <br /> : <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Iblue, Awn Owner: hNnan <br /> Address: <br /> f e ILA( L.A 9 S-1 1 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: � 0 O Owner: Xn <br /> Address: D,_,)C)(P f-CA f-C C.') <br /> Service You Provided: ( �� <br /> Supervisor Name and Contact.In ormation: �O CANt <br /> Bloodborne Pathogen Training: Submi C tificate <br /> Date Completed: , Trainin Provided b l 1 <br /> Hepatitis B Vaccination Statt4: 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: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/ Fax: <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 certify that to the best of my knowled a and belief thLe,statements made herein are true and correct. <br /> Signature: ' '7s Date: <br /> Print'Name: Vt(AY-(,i Title: <br /> FOR OFFICE USE ONLY �'e' <br /> Program (PE): :li Fees: ' .. , Authorized by(RENS): .n�K�...Rate Entered: <br />