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San ]oaquin County 1868 East Hazelton Avenue <br /> .r Stockton,CA 95205 <br /> environmental Health Department` 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 MBody Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMA ON: )) (� <br /> NAME: ` Phone: n ( q -1 o <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: b Z- 6 - 1 Z Gender: F o M (circle one) <br /> Identification Type: MDrivers License ther Identification No.: <br /> Facility where Body Art Services Will be Provided 1 ( ip <br /> Facili Name: QS' (� R+-}-O U Owner: <br /> Address: '?Ilk 5 t JW S - <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: fAQ T iiOr-1 <br /> Address: ('1'7 S A,k iA � <br /> Service You Provided: lc(x�(«' <br /> Supervisor Name and Contact Information: C7 l G`i ei GCl �j�,o Z��j 6=3 CA <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: b �l/�7 d Training Provided b CVS (c((ni f1 .(oy-n <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[=Laboratory Evidence of Immunity 1:9 <br /> Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: lli�? ? <br />