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------------ <br /> San 3oaquin Col. ntij 1868 East Ha7elton Avenue <br /> Stockton,CA 95205 <br /> Eraviramranentall Heath" Dapai'tre`en6 Tel: (209)468-3420 <br /> Flax: (209)464-0133 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> HECHANICAL STUD AND CLASP EAR PIERCXMG MOTIFICATKOH <br /> ppacr--DljRr--S-to BE PERFORMED:Check all that apply(see back for definitions) <br /> Wjlattoolng Mbody Piercing MMechanical Stud and Clasp Ear Piercing <br /> MBranding ®Permanent cosmetics <br /> H� PEQU I RED nE-:GjS m RATIOW,P E RNIXT,(Pfd N@ Y a F-XAT jo M 6-EES:Check all Ith at apply, <br /> !MAnnual Body Art Practitioner Registration 3F-I0-1Mechanical Stud and Clasp Ear Piercing Notification <br /> 20 Annual Body Art Facility Permit <br /> Ill.APPL-KCANT INV-QRHATIGr,: <br /> I 11%. Phone: 2z ® (.29 -76 11 <br /> <br /> <br /> <br /> Date of Birth: Gender: MF (circle one) <br /> Identification Type: Drivers License Mother identification No.: <br /> Facility viliaere Body Art Services Will be Provldc-d el r— 3AA" 140\ qUIA <br /> Facility Name: Owner: <br /> Address: <br /> f <br /> Evidence of Six-months of Related Experience <br /> Facility Name I-VC-V-U 4o+-fco Owner: 34VV\1fA <br /> Address: 191 16L &11 - <br /> t <br /> Service You Provided: <br /> Own CA— <br /> Supervisor Name and Contact information: <br /> Bloociborne Pathogen Trafning:Submit Certificate <br /> Date Completed:VV\CLr-I I ®701057 Training Provided by: C <br /> 1-4�cp -v it D <br /> atjtjs B Vaccination Status:C[loose one and Sub n acur. entation <br /> 1wertification of Completed Vaccination 3Mcontraindicated for Medical Reasons <br /> 2[:]Laboratory Evidence of immunity 4 Vaccination Declination <br /> LOCAT IOM (S):(Attach additional sheets as necessary� <br /> W. ILITY ttach addit <br /> .. .USINESSMAME- r1UD'e-')q !W <br /> Location address: Uv M Suite: <br /> City: <br /> C I Z113: C-�-1:3,2S County'. CP QIM State: C)A— <br /> owner/Contact: Phone/Fax: <br /> Z. BUSINESS MAME: <br /> Location address: Suite: <br /> City` State: ZipCounty: <br /> —L---� <br /> Owner/Contact: Phone/ <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 /> Nerero� 'e have!n are twue ancl cu-h-VaC2. <br /> f the statements Mad <br /> Signature: Date: —0— 1 <br /> Print Mame: O Title: ---0-4Ae-C <br /> X�rI Scj 49af <br /> Fees: AuharizEd by(REl.S): Data,Entered: <br /> f2 <br />