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San Joaquin County 1868 East Hazelton Avenue <br /> CA 95205 <br /> Environmental Health Department Stockton,46 <br /> Tel:(209)468--34203420 <br /> Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCED ES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> ., Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> BrandingEDPermanent Cosmetics <br /> II.REQUIR 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 /> z[::]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: �J ` t / <br /> NAME: Wro\u- �l�'+IVA CSC-Q.Zi J r Phone: EO"') x"12 ��� �► " <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 6-7, 55 Gender: M or j(Zr (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> t <br /> FacilityName: k \ "\ 1 00 Owner: U 1' 8 S L a Ir P,c v, <br /> Address: _L0000 Gk. <br /> Evidence of Six-months of Related Experience <br /> Facili Name: V' ty �L)r Owner: <br /> Address: L 1 +2 <br /> Service You Provided: e-� 'CL <br /> Supervisor Name and Contact Information: (_ �`0 rr2 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed, 2� Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3HContraIndicated for Medical Reasons <br /> 2QLaboratory Evidence of Immunity 4_Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <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 Ea4governing <br /> n and agrees to operate in accordance with all applicable state and local <br /> requirementdy art practices or practices governing mechanical stud and clasp ear piercing. <br /> I here -cerof m nowle e a belief the statements made herein are true and correct. <br /> Signat re: i/ Date:Print Name. j Title: ��TOJ ��� G ( O,�l <br /> FOR OFF E E ONLY <br /> Program(PE): s: Authorized by(REHS): Date Entered: <br /> If2 <br />