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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA 95205 <br /> 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 /> E21fattoolng Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding <br /> <br /> nnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2MAnnual Body Art Facility Permit <br /> III RMATION: 2 _ �,. (\ 7� <br /> NAME: Cir IGt.Md 0 ay'r os Phone: -04 3 I Z ` 2329 <br /> HOME ADDRESS: dI G'ICl5 eept e, Email : nl6orrat.Vn S �o �� Cov� <br /> Cit Ot c1 State: Opt zip: Count C� <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth : Z O - f `I `f 1A Gender : ETFJ o M <br /> (circle one) <br /> Identification Type : r7TDrivers License MOther Identification No. : {- Zo SL rNv <br /> D V I <br /> Facility where Body Art Services Will be Provided <br /> FacilityName : GIC mJ � >L Foe ) Owner: P 5m . *L eve, d0 <br /> Address : iir, 54- mmw� T3 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: V C k 1 Y" +- +too Owner: C eLv K2 %e�tdo Z rn <br /> Address: II ( h f- 844"I-eti 9L 5` 36 <br /> Service You Provided : ,i <br /> Supervisor Name and Contact Information : WO �P.V K4404-MJ O o 6 SS q rz/ <br /> Bloodborne Pathogen Training : Submit Certificate <br /> Date Completed : 6 ` Z S � Z- I Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1�Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S) : (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address : Suite : <br /> City: State: zip: County : <br /> Owner/ Contact: Phone/ Fax: <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 governing safe body art practices or practices governing mechanical stud and clasp ear piercing . <br /> I hereby certify that to the best jyf my knowledge and belief the statements made herein are true and correct. <br /> Signature : �� (/""'�`-'� Date : l z — 2 Zt72 <br /> Print Name : Ar ( a.v�jd Tz�)IJry' /o Title: `Tel, 00 9-r it, g )t- <br /> FOR OFFICE USE ONLY <br /> Program (PE) : q 11 () Fees : 51607 Authorized by (RENS) : Ol N 6-61 Date Entered : <br /> �uv ZI I I ==]f 2 <br />