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San Joaquin County 1868 East Hazelton Avenue <br />N- w , Environmental Health Department Stockton, CA 95205 <br />; affk.in; 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 INPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />IMAnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br />2[::]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 0) <br />1 lei I <br />Gender: F <br />or M (circle one) <br />Identification Type: Drivers License Other <br />Identification No.: <br /> <br />Facility where PB,ody Art Services Will be Provi ed <br />FacilityName: V ave I� f/ c U <br />Owner: <br />Address: I <br />t2U 11&6101 NLMOWA CA <br />AP5;'3I <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />r� <br />Date Com leted: ' - D Training Provided <br />by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />IMCertification of Completed Vaccination 3r'lContraindicated for Medical <br />2[=Laboratory Evidence of Immunity 4[=Vaccination Declination <br />Reasons <br />IV. FACILITY LOCATION (S): (Attach additional sheets as <br />owner/contact: 4rUlU�`�'�}(,�FI(>,✓i' Phone/Fax: �ilxj Cpy`p`i 1Q��1� <br />2. BUSINESS NAME: <br />Location address: Suite: <br />City: State: Zia: 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 that o It e best of my knowledge and belief the statements made herein are true and correct. <br />ISignature: Date: I, &L <br />Print Name: t A[ Title: (• %07)?i <br />FOR OFFICE USE ONLY <br />Program (PE): H I1 0 Fees: J 1602 Authorized by (REHS): 61 <br />{y 6N Date Entered: <br />