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San 3oaquin County 1868 Ea=t Hazelton,Avenue <br /> Stockton,CA 95205 <br /> far Enuirrgn nental HealltCri Department (209)468-3420 <br /> Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGESTRATIOM/ <br /> NIECHANICAL STUD AND CLASP EAR PIERCING MOTT FICATT"0 H <br /> ppocr--DURES TO Era PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing MMechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics <br /> JZ.PEAU IRED Rr--GjS7RA71 HKON,PERMI-j,C)p,NoTI-FICA yj!G11 FEES:Check all that apply. <br /> Annual Body Art Practitioner Registration 3MMechanlcall Stud and Clasp Ear Piercing Notification <br /> 2Annual Body Art Facility Permit <br /> P—A <br /> 111.APPLECANT XWORHATIZON- <br /> Phonf:—taq) UQh 21L0 <br /> <br /> <br /> <br /> BODY ART PPIACTITIONER OMLY: <br /> -X=lh <br /> Date of Birth: QI 2(o ME <br /> Gender: F or M (circle one) <br /> —V <br /> Identification Type: 11�- ivers License Mother Identification No.: <br /> Facility where SadV Art Services Will he Provided <br /> Facility Name:. W V mi Sw I T'C&M .. Owner: (664Hr <br /> Address: 13 W YareMitt A VC <br /> Evidence of Si---months of Pelated E,,tperierice <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact information: <br /> BloGd-lbarne Pathogen Tra!ning:Submit Certificate <br /> Date Completed: 3: 1 Zq-1 lu Training Provided by: A 12=Ir-W r� C MI <br /> Hepatitis B Vaccination Sta-tus:c1loose one and Submit Documentation <br /> IN I Certification of Completed Vaccination 3Mcontraindicated for Medical Reasons <br /> L--j <br /> 2MLaboratory Evidence of Immunity 412! Vaccination Declination <br /> KV.FACi-LIXTY LOCATION (S):(Attach additional sheets as necessary) <br /> 11. BUSINESS MAME: � Ta4&D <br /> Location address: I Yo fe M.11C A VC Suite: <br /> City: HeInt=a State: Ch zip: S5 ,33-1 County: ,[An-jclaqon <br /> Owner/Contact: (J)rls .. Md-lhev-SOT) Phone/Fax: (70,1) <br /> 2. BUSINESS M- AME: <br /> Location address: Suite: <br /> City: State: Zip: ---Coun-LV: <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 b t practices or practices governing mechanical stud and clasp ear piercing. <br /> Ls 'ah-veiraF tMe-MCICU'Vec� <br /> Ed N a w e c e V '':heat t©` lledge Find Lellefu th�--ZtFjtc-ment rnad ic we L <br /> Signature: Date: <br /> Print Name: Title: <br /> F,OR Off-Kfl- USE ONLY <br /> Peogram alm (PE) Fees: Authorized by(RENS): D ate Entered: <br />