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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205Tel: (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 />Branding ®Permanent Cosmetics <br />II. REQUIRED REGISTRAT%ON, PERMIT, OR NOTIFICATION FEES; Check all that apply. <br />I=Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2E]Annual Body Art Facility Permit <br />II <br /> <br />BODY ART PRACTITIONERANLY <br />USE ONLY <br />Date of Birth: 0 S <br />` <br />1 <br />Gender: M <br />or (circle one) <br />Identification Type: Drivers License Other <br />Identification No.: <br />Authorized by <br />Facility where Body Art Services Will be Provided <br />Facility Name: L b� rTGt. o <br />//�� <br />Owner: &K J <br />Co r i c- <br />Address: <br />C;A <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: Y\ C <br />DY 2Ct7 <br />Address: 567L h <br />Service You Provided: ME <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: �`y�L TrainingProvided by: <br />q t,,, <br />'T'Cy/OY�- :f�t tr> <br />C'.Nyt� <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r7Certification of Completed Vaccination 3r"IContraindicated for Medical <br />2MLaboratory Evidence of Immunity 4MVaccination Declination <br />Reasons <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />Location address: Suite: <br />CItY: State: Z(p: CountV: <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 governin safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />19erebV certify t t t st Pmy knowledg' nd belief the statements i ;e herein are true and correct. <br />Si nature: Date:Print Name: WLt7 Title: <br />FOR OFFICE <br />USE ONLY <br />Program (PE): <br />yJ/ 0 <br />Fees: �/,rj ,z <br />Authorized by <br />(RENS): Date Entered: <br />