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e0GKC0�, „a�yeu� <br /> Ilc�.�artninnt� 2 C <br /> _ 6•wa se r.•+•+��»nt^+1 4J�•alth VJ , I„ <br /> J..+ l.l,�.rl JJLVJ <br /> Environmental Health Department 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:Check all that apply(see back for definitions) <br /> �ttooing [::]Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> QBranding QPermanent Cosmetics <br /> II. REQUIRED R ON,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> ual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit l IJ J! <br /> III.APPLICANT INFORMATIION: a �,7 �J L— <br /> NAME: 7 / �,Y Phone: O` <br /> HOME ADDRESS: f �/I 2 Email: —�i✓fL�/ �� ���•G G�''� <br /> City: fif1� State: zip: <br /> S 2 Coun <br /> Date of Birth: �j4 / 9 Gender: F o e one) <br /> Identification Type: MDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Prov <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> iercing. <br /> I hereby certify t t o the best my kt1te6adelief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: , Title: <br /> . 2 <br />