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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 /> Tattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding M Permanent Cosmetics <br /> <br /> Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III. APPLICCAANT INFORMATION: f� 1� +-� p M� <br /> NAME: -1 ALU (a0If\ �jf" V6C7)yrS `A Phone: C� I 00 I I ! ' CQ J2 Co <br /> HOME ADDRESS : V5944 EL LII S L &)) '-7 Email: ' FI P SI fUleo ® gAt4C I. GCi7VL <br /> Cit : t � c OL State : C A - Zi 15 ( County: Sao Unv <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth : Gender: F or M (circle one) <br /> Identification Type: Drivers License M Other Identification No. : <br /> Facility where Body Art Services Will be Provided <br /> Facility Name : 1 S « . Owner: 5A L O M on 15 RP Ac sA , <br /> Address : <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address : <br /> Service You Provided : <br /> Supervisor Name and Contact Information : <br /> Bloodborne Pathogen Training: Submit Certificate /� 1 .y� � ,( p <br /> Date Completed ; " Z 02 t TrainingC Provided b : T7 � J <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3[:]Contra indicated for Medical Reasons <br /> 2[:::] Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S): (Attarch additional sheet's as necessary) <br /> 1. BUSINESS NAME: f I /V J� 11 S � ,f r , V lie" �T r� <br /> Location address: L � 9 LJ ;/ � 5 '� ivy r ( G Suite ; <br /> City: M (4 A) r E�C A • State: Zip: 73735 6 County : SAS tx16? U tlV <br /> Owner/ Contact: Uj 1 0 ) �7 I dq Cl1 I ':v 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 ody Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud and Ear Piercing Notific io agrees to operate in accordance with all applicable state and local <br /> requirements govertNL t practices or practices governing mechanical stud and clasp ear piercing . <br /> I hereby certify tha owledge and belief the statements^made herein are true and correct. <br /> Signature: Date: <br /> Print Name : Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE) : Fees : Authorized by (REHS) : Date Entered : <br /> I if 2 <br />