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San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Environmental Health Department Tel: (209) 468-3420 <br />'- <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: C eck all that apply (see back for definitions) <br />Tattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1[ZAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2[::]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: 1 `, f 1 <br />NAME: IG(AI{`sUr IWOA0,1 L' CAk0 Phone:l20? SL 1ya 07)2 <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 10 15 zoo <br />Gender: F <br />r M (circle one) <br />Identification Type: 157MDrivers License MOther <br />Identification No.: <br /> <br />Facility where Body Art Services Will be Provided <br />Authorized by (RENS):. <br />Facility Name: G Q, f� <br />Owner: <br />Address: TS <br />I C 9 3 <br />Evidence of Six -months of Related Experience <br />Facility Name; e;Lm 1s 1e.V1,I Iii Owner: 105kl <br />Address: ZSZS 5•4bkkiiNT <br />7. Li <br />Service You Provided: &A PiOrc i vil <br />Qwii <br />Supervisor Name and Contact Information: (I of <br />iL 0A, Z 69 <br />3 i t3 <br />21 Z <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 10101262 Q Training Provided by: GZ t e <br />Hepatitis B Vaccination Status: Choose One and Submit <br />Documentation <br />1r7Certification of Completed Vaccination <br />3r'lContra indicated for Medical <br />Reasons <br />2[Z]Laboratory Evidence of Immunity <br />4daccination Declination <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 tha • to he best o 3 !f m knowledge and belief the statements ma a herein are true and correct. <br />Signature: Date: 05 � Ld Z/ <br />Print Name: 1 ll Yt I tc 6YI L f� (( th Lwt Title: <br />OFFICE USE ONLY - - <br />3m (PE): 4110 <br />h <br />Fees: <br />Authorized by (RENS):. <br />JINCsN Date Entered: <br />h <br />