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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) 464-0136 <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 Mmechanical Stud and Clasp Ear Piercing <br />Branding oPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1MAnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br />2QAnnual Body Art Facility Permit <br />III. APPLICANT '` <br />INFORMATION: �1 <br />NAME: 1-4XNA M�trtin�z-Tcnit Phone: UrHiJl)Ll�'5UUcl <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Att <br />Date of Birth: I Z` LI IU <br />Gender: <br />RM or MM (circle one) <br />Identification Type: EmDrivers <br />License Other <br />Identification <br /> <br />Facility where Body Art Services Will be Provided <br />Facili Name: %L� 'P <br />Owner: AnclreW <br />ZSc1&LAia <br />Address: 15 3 3 LIL Shreti, E, udoyi CA <br />q.537.o <br />Evidence of Six -months of Related Experience <br />Facility Name: L tj ci <br />Owner. J6rN <br />� <br />Address: 6111 W &x nil I Nve, <br />Service You Provided: Taftu� or <br />i 1 <br />Supervisor Name and Contact Informatio -11y <br />J - <br />2-05 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Com leted: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination <br />3MContraindicated for <br />Medical Reasons <br />2[.::]Laboratory Evidence of Immunity <br />4MVaccination Declination <br />ach additional sheets as necessary) <br />city: �SCCItICi1 state: [;{e zip: L�S32.0 County: SAYL�OfluLli/'I <br />Owner/ Contact: ELULAV^Btn/ ijn1LjQUUC Phone/ Fax: ZUC) w:IU=QjLIO <br />2. BUSINESS NAME: <br />City: <br />The undersigned hereby applies for a Body Art <br />State: <br />Zip: <br />County: <br />Owner/ <br />Contact: <br />Phone/ <br />Fax: <br />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 />reMU irements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify that t ",be be my knowyledge and belief the statements made herein are true and correct. <br />Signature: / Date: 5' 2 j s ZZ <br />Print Name: Ua in cNKLriiY1P rr] i+ Title: <br />L. <br />OFFICE USE ONLY <br />3m (PE): 4110 <br />-Fees: ISL Authorized by (KERS): GpAo Date Entered: <br />