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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 MBody Piercing r7mechanical Stud and Clasp Ear Piercing <br />Branding ®immanent 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 />2C]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATIOON: , G <br />NAME: r��Ml�( /_� erg �d-1 Phone: Z/ vtt Q G 2- <br />< <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Att <br />USE ONLY <br />Date of Birth: 7' 0e? - Ml l <br />Gender: F <br />or M (circle one) <br />Identification Type: MDrivers License M Other <br />Identification No.: <br />Fees: 'g ((,Z <br />Facility where Bo?y Art Services WilLbe Provided <br />FacilityName: �1 at/oll � '(D (�.� G - <br />/ <br />Owner: �r({'� <br />/ <br />T <br />Address: <br />Evidence of Six- onths of Related Ex�plerie ce9 <br />FacilityName: Oft n( Z7 /Q L211 <br />J J <br />Owner: ( Y 1. / ie <br />Z brYM%"j L' ) <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information )-%G <br />Bloodborne Pathogen Training: Submit Certificate <br />Date completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertificatlon of Completed Vaccination 3MContraindicated for Medical <br />2[.:]Laboratory Evidence of Immunity 40DVaccination Declination <br />Reasons <br />ach additional sheets <br />Location address: /7 `% I <br />l�i1���� <br />City: State: Zip: - �72 County: CA 11 <br />Owner/ Contact: Lo f-11wag, l rYi411Y)t Phone/ Fax 2a _ 64;3q — 6 Li <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 cert <br />ify t a to the best of my <br />� - �ryr%� <br />Print Name: t; IA", 1�YLM n ii <br />and belief the statements made herein `t��ta'r'e�ttlr�ue and correct. <br />Signature: <br />Date: (]1L" 1"t' �V e-�. <br />Title: <br />OFFICE <br />USE ONLY <br />3m (PE): <br />t./ ((� <br />Fees: 'g ((,Z <br />Authorized by <br />(RENS): Date Entered: <br />