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San Joaquin County 1868 east Hazelton Avenue <br /> Environmental Health Department; Stockton, cA 93420 <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 MMechanical Stud and Clasp Ear Piercing <br /> Branding <br /> <br /> E; IAnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III. APPLICANT <br /> INNFORMATT\I,OnN1 : <br /> NAME : MiSIcat \ I U1M w U_ e Phone ' UCAl "/ � l - <br /> XA <br /> HOMEADDRESS : � 46 r\Vt Email ( \( y-&bur <br /> 1 ;). D , (rwli ( C �� <br /> ( T— <br /> City : Mcltl� (� (1� State: CP� Zip ' qf-�r4l-)L; County ' <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth : (3 . D I 'I G 3 Gender : F or MM (circle one) <br /> Identification Type: MDrivers License Other Identification No. : <br /> Facility where Body Art Services Will be Provided <br /> Facility Name : Owner: <br /> Address : <br /> Evidence of Six-months of Related Experience <br /> Facility Name : V) l4- Owner ( <br /> Address : (w0 <br /> Service You Provided : V-Q - \y. <br /> Supervisor Name and Contact Information : <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed : Training Provided by : <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3r'lcontraindicated for Medical Reasons <br /> 2[j] Laboratory Evidence of Immunity 4 [=Vaccination Declination <br /> IV. FACILITY LOCATION (S) : (Attach aaddittiion`al' sheens has necessary) <br /> 1 . BUSINESS NAMEE:7 1 ` nyc \of ; l y V (� V1 �/1 (I� V K--I t <br /> Location eaddress : / .� � 1 `� r(Al 'fl SiT Suite ' <br /> City : NA(Anw " L ` State : l }fit Zip' 016e, 2) (a County ' rN � 'N (J7-UN <br /> Owner/ Contact : ,SOI, (G\ bPC{ hltl `-( Sa Ill 11 Phone/ Fax ' CaCG ) q55 s J (7(b <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 of my knowledge and belief the statements .made herein are true and correct, <br /> Signature : � a.L Date : a0I <br /> v (/ ,1 <br /> Print Name : C4161P,1"ht WnmO,rytC Title : rjWj1V ar+- <br /> FOR OFFICE USE ONLY <br /> Program ( PE) : Fees : Authorized by ( REHS ) : Date Entered : =1 vf <br /> 2 <br />