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EM <br />Sin Joaquin Cotinty 1868 East Hazelton Avenue <br />*_artmenStockton, CA 95205 <br />Environmental Health Dept Tel: (209) 468-3420 <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATIO <br />'0 <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFicA71kCCE1 JED <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) sp 0 6 201Z <br />gTathoing [:]Body Piercing [:]Mechanical Stud and Clasp Ear Piercing TH <br />Branding [:]Permanent cosmetics ENVIRONMENTAL HEAL <br />11. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />iCZAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2PUlAnnual Body Art Facility Permit <br />L." <br />III. APPLICAIVT XNFORMATIa;A,, ) \X <br />NAME.• <br />Y_ <br />Phone: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Date of Birth: oi:5 LT7 775Z <br />Gender, MF <br />or IV (circle one) <br />Identification Type: WDrivers License Mother <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />/ Ullhl trjt4on Owner, <br />01 U I <br />Evidence of Six -months <br />You <br />Owner: I— enc C) <br />Bloodborne Pathogen Training. Submit Certificate <br />nate CnMnleted! 0-7 /0 5-7 117-01 -;rrainina Provided by: P t20 Ci(`_ Vk CA <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1 [Z] Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br />2[Z3Laboratory Evidence of Immunity 4Mvaccination Declination I <br />IV. FACILITY LOCATION (S): (Attach additional sheets as <br />1. BUSINESS NAME: L u c, V_ i i it in ) <br />QAWTWIKM� <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 />Signature: <br />Print Name: -FaTATIRIMIMIZA <br />