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" San Joaquin County 1868 East Hazelton Avenue <br />�� {' Environmental Health Department Stockton, CA 9s2os <br />$;:>' Tel: (209) 468-3420 <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATIO <br />IO <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICAT <br />I 0191M <br />I. PROCED RES TO BE PERFORMED: Check all that apply (see back for definitions) FF f <br />Tattooing Body Piercing Mechanical Stud and Clasp Fa� ® % <br />Branding Permanent Cosmetics E� SNTgCH <br />II. REEAnrual <br />REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. s <br />1 Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMA <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth; <br />Gender: F r M circle one) <br />Identification Type: Drivers License =Other <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: L'I O. \ S <br />_ <br />Owner: 1 Ct <br />Address: 2.' G ski f <br />C <br />e <br />F c ility Name: `-1i1 r ��r �\� ` <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />q <br />l' <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 12 2-0 14 Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1 Certification of Completed Vaccination 3 M 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: UMI l- \OS <br />M <br />City: tianim State: C & Zip: q533fo <br />County: San C*sc1gU�� <br />Owner/ Contact: T -O \fi Sl &-Q Phone/ Fax:( �oi(� * 13 <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 a to th best ofmy wledge and belief the statements made herein are true and correct. <br />Signature: Date: 5-13-1 <br />Print Name: Title: <br />FOR OFFICE USE ONLY' <br />Program (PE): 0 Fees: 1,5-z,:00 Authorized by (RENS): ate Entered: <br />