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• San Joaquin County 1868 East Hazelton Avenue <br /> i" Environmental Health DepartmellC 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 Mechanical Stud and Clasp Ear Piercing <br /> Branding EDPermanent Cosmetics <br /> II. REQUI ED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III. APPLICCANT INFORMATION: <br /> NAME: f' N"'A:r ZC 'GI 1 15 <br /> Phone: <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 10 - 011 C, Gender: r F or IV (circle one) <br /> Identification Type: r7iDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: I� r.� r tZ�' Owner: Cr,(-Su <br /> Address: ewL AV?, <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 /> 1MCertification of Completed Vaccination 3=Contra indicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4=Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: V 1$ ckk C�I'NrcM�r <br /> Location address: (/yS 'V4 ln� Suite: 12.4 G <br /> City: ,� p .,k\sn, State: LGk Zip: �lS`ZZc County: �OAgOrj <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 that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: f7 r C_ c,/n Tyr"AA"J 5 Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): //0 Fees: Authorized by (REHS): = MC& to Entered: <br /> if 2 <br />