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aM + sz 1868 East Hazelton Avenue <br />,.4 San Joaquin County Stockton, CA 95205 <br />Environmental Health Department Tei: (209) 468-3420 <br />*, <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCED ES TO BE PERFORMED: Check all that apply (see back for definitions) VE <br />17ITattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br />Branding OPermanent Cosmetics <br />SEP 86 2012 <br />II. REQUIR REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. ENVIRONMENTAL HEALTH <br />1 Annual Body Art Practitioner Registration 3M Mechanical Stud and Clasp Ear Piercing NotO a /SERVICE$ <br />2[::]Annual Body Art Facility Permit <br />III. APPLICANT NFORMATION: <br /> <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 0j,/01110A)_Gender: M <br />ror <br />M (circle one) <br />Identification Type: riDrivers License i;FOther Identification No.: <br />Facility where tBody Art Services Will be Provided 1 - \ <br />FacilityName: LUG�1 6lii <br />00 Owner: O �'1 1n 1�0 U; ✓\ <br />Address: <br />Evidence of Six -months of Related Experience <br />Facility Name Owner: <br />Address: <br />Service You Provided: h <br />Supervisor Name and Contact Information ('� O U n <br />Bloodborne Pathogen rai ing: Submit Certificate <br />Date Completed: <br />S 2Z O TrainingProvided b: lit/ S otv- <br />Hepatitis B Vaccination Status: Choose One and Submit Docu91cc <br />tion <br />1MCertification of Completed Vaccination 3ntraindicated for Medical Reasons <br />2QLaboratory Evidence of Immunity 4MVaccination Declination <br />IV. FACILITY LOCATION (S/): (Attach additional sheets as necessary) <br />IL. BUSINESS NAME: L b r, `L a ve U -y-c4l,[oU <br />Location address: 17/ (v kin c-,� �- Suite: <br />city, 4State: Zip: S 33 County: 52h <br />nwnPr/ Cnntart: -':G � h Phone/ Fax: 2 cl- n Z.. <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 s e body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify that t s of my knowledge and belief the statements m e h rein are true and correct. <br />Signature: <br />Date: <br />Print Name: d 0 v Title: o, ° / <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (REHS): Date Entered: <br />f2 <br />