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k <br /> San Joaquin County 1868 East Hazelton Avenue <br /> "*0 Environmental Health Department Stockton, CA 95205 <br /> 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 /> Tattooing Body Piercing F7mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III. APPLICA�T C <br /> INFORMATION:/1,,, ^ <br /> NAME: f�►���Y �12aY11�I� <br /> 1/ Phone: ���'- J L�`� �✓� <br /> HOME DRESS: r-I— IlEy Email: } <br /> Cit L' +Q State: A4 Zip: County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: — /2_/f & Gender: FF-1 or FPF cl.Ale one) <br /> Identification Type: fivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided _' .. y <br /> Facilit Name: ca O 6 Owner: Gu✓( k / ter <br /> Address: 169 Z SU+�C _q��4 gSZv <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 r7 Certification of Completed Vaccination 3r7 Contra indicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4 F71vaccjnation Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: [� /� Suite: ;?'01A <br /> Cit State: Zi 5� County: <br /> Owner/ Contact: Phone/,Fax: <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 t at to the best of m know) dge and belief the statements made hereiin,are true and correct. <br /> Signature: - Date: CQ� <br /> Print Name: Title: ts.c <br /> FOR OFFICE USE ONLY <br /> Program (PE): L111 o Fees: uJ Authorized by (RENS): Date Entered: <br /> -t� If <br /> 2 <br />