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• San Joaquin County • 1868 East Hazelton Avenue ] <br /> Stockton,CA 95205 <br /> Environmental Health Department 468-3420 <br /> �. evej)BODYART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> Jf IN a IQ <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) 1012 <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Pierdngwi E <br /> [::]Branding Permanent Cosmetics PERMIT E1� ES'*��7 <br /> II. REUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICA T INFORMATION: <br /> NAME• Phone: �- <br /> HOME ADDRESS: I IG Email: <br /> City: State: Zi Count : <br /> Date of Birth:3' Gender: F or MM (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Servic Will be Provided /. <br /> Facility Name: Owner:!Lw <br /> Address: C4 k <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Ls Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathoge Training: Submit Certificate <br /> Date Com leted: ( )— Training Provided b L <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 r__j Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4[::]Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) \\ 1 <br /> 1. BUSINESS NAME: Ir 7r <br /> Location addre s: Suite: <br /> Cit State: Zip: Count <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 1 owledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: <br /> Title: �Q <br /> Q <br /> ��}� 0 '7 <br />