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0 San ]oaquin County 1868 East Hazelton Avenue <br />Sto95205 <br />Environmental Health Department el: (209)kton, 46 -3420 <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 />rPVattooing ®Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br />®Branding ®Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />i Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />20Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: Phone: 0 - �c , <br /> <br /> <br />w <br />x I b RAC1ITflIER>l�IL1f�'� {fid <br />u. <br />. t �.�>.._; <br />..��. ,.: <br />Date of Birth: C76 - v - J Gender: F o . M (circle one) <br />Identification Type: MDrlvers License JC7f0ther Identification No.: \ , <br />Facility where Body Art Services Will be Provided <br />Facili Name: o i V Owner: ca y, <br />Address: E . L AG-'/ -3 <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 Com leted: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />T71Certificatio, of Completed Vaccination 3®Contraindicated for Medical Reasons <br />2[Z]Laboratory Evidence of Immunity Itis ` , ( 4 Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME:r <br />Location address: i,3 �-/6"?, 5.4 L1104 Suite: A <br />City: (ocy-ef-oState: LA <br />Zip: 4 !2' County' <br />Owner/ Contact: -7_60C4 bg&co s� 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 that to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: c Date: ) '2_ 11--1 t! <br />Print Name: Title: <br />