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San Joaquin County 1868 East Hazelton Avenue <br /> 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 ®Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> ®BrandingLdPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> LA <br /> 1 Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: 1 <br /> NAME: Qu1Or M. PerrQLAU Phone: aocg 15 09) <br /> <br /> <br /> c BOI1'- RT PRIRITITVNE1# 3Yl <br /> Date of Birth: Gender: F or M (circle one) <br /> Identification Type: 1XIDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Fres 1®( — d L Owner: <br /> Address: SAO�T G. q 3-1 a221,, <br /> Service You Provided: n kckl BUY'®LU <br /> Supervisor Name and Contact Information: .m `e Ct. <br /> Bloodborne Pathogen Training: Submit Certificate y� <br /> Date Completed: 9 TrainingProvided by: CZC. n K e Cro SS <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3®Contraindicated 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: e, Fr ec t Tctttoci <br /> Location address: 1110 W. e Suite: <br /> Cit State: Cc, Zi tCounty: &a int <br /> Owner/Contact: r LA('knt i p\, 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 t at to the best of my knowled a nd belief the statements made herein are true and correct. <br /> Signature: �� Date: <br /> Print Name: Qr lex cc - Title: <br /> f2 <br />