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1868 East Hazelton Avenue <br /> San Joaquin County <br /> Environmental Health Department Stockton,CA 95205 <br /> 1 Tel:(209)468-3420 <br /> Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD ARID CLASP EAR PIERCING NOTIFICATION <br /> ?.P CEDURS TO BE PERFORMED:Check all that apply(see back for definitions) CEIVED <br /> Tattooing ®Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics (J( � 2 2012 <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Checi<all that apply. EI�I <br /> 1 Annual Body Ari:Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing C�oLWR ENTAL HEALTH <br /> /SERVICES <br /> Awual Body Ari_Facility Permit <br /> III,APPLICANT INFO'RyM��A+TTIIOON::', (� 1 <br /> NAME• KL \\.1C't'll" gc'y �\6 - Phone�ZiCQ�J Z1L►`� � <br /> <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 'l ' Ig c Gender: F or (circle one) <br /> Identification Type: rivers License — Mother Identification No.: <br /> Facility where Body Art Services Will be Provided ti <br /> Facili Name: eAV Owner:, W <br /> Address: 7'7 <br /> Evidence of Six-months of Related Experience W� <br /> FacilityName: 9-7rG V ATT 0 10 Owner: �° \ �' <br /> Address: ii Z <br /> Service You Provided: c) <br /> Su ervisor Name and Contact Information:1-rw (I <br /> Bloodborne Pathogen Training:Submit Certificate Y <br /> Date Completed: ZOed- Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3[7]Contraindicated for Medical Reasons <br /> 21MLaboratory Evidence of Immunity 4t&lccination Declination <br /> IV:FACILITY LOCATION((S):(Attach additional sheets as necessary) <br /> I BUSINESS NAME• k j� V� Y�1G \r+ y1 —o <br /> Location address: Suite: 6:::Ci r State: Zi Coun WJ ky\ <br /> Owner/Contact: Phone/Fax: Z— 11 <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 /> 's hereby certify that tot of my kr� d of the statements made herein are <br /> true and correct. <br /> Signature: Date: gkz L <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(RENS): Date Entered: 1 B <br /> cMv Iu P7 <br />