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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA -3420 <br /> l P Tel: (za9) a6s3azo <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 /> ooing r7Body Piercing r7Mechanical Stud and Clasp Ear Piercing <br /> LJ <br /> Branding ®Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. ' <br /> �nnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2MAnnual Body Art Facility Permit <br /> III.APPLI ANT INFORMATION: /� {� <br /> NAME: Vz <br /> ' Phone: /:1/9 <br /> HOME ADDRESS: \ Email: 1 t I • <br /> City: Ubh 1 State: (,Pr- Zip• — 1 , County <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: M or M (circle one) <br /> Identification Type: twivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided A v� n �n <br /> Facility Name: A-ffkv S Owner: Vj i y vt.��' T <br /> Address: <br /> Evidence of Six-months of Rela d Experience <br /> Facill Name: 1pitZ�!/�ll. Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Tr fining; qubmit Certificate <br /> Date Completed: Trainin C <br /> Provided b : f ✓l-O VI. <br /> Hepatitis B Vaccination tatus: Choose one and Submit Documentation <br /> 1=Certification of Completed Vaccination 3=Contraindicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION S): (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location add! s Suite: <br /> City: Stater ZIP: _77-2 ouunt <br /> Owner/ Contact: (Vk Phone/ Fax: vn -p �j <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 governi g safe bo art practices r practices governing mechanical stud and clasp ear piercing. <br /> I hereby c rtify at o the best f y kno ge and belief the statements m de her in are true and correct. <br /> Signature: Date: <br /> Print Name; Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): q1I Fees: dj$o2 Authorized by (REHS): 61NCr(-I Date Entered: <br /> f2 <br />