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San Joaquin County 1,4bN 1.151 H370011 AVMU% <br /> 1 Environmental Health ODepartment `.•tockton,r'A o,;05le::(ZNI 4611-.1420 <br /> F1•c-i?ngI4nd n'iR <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES FO BL PERFORMED:C.hmk all that dPply(!A!I!lie.k lot del:nil.tx".) <br /> [Alattoning FiBody Piercing Fi`fechanlcai Stud and Clasp bar Parsing <br /> 0 Brandino crmanent Cot rnctics <br /> QP �i'C'Y'/1 t- �C.1' "n.c_.✓lr�.� M i C_r'�5,bl ckd L, Vrj <br /> I_. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION rEES C'Ivtk all that apply. <br /> tQAnnuat body Art Practitioner ReglstraI 3QMechanlcal Stud and Clasp Ear hlercing tdotfication <br /> :=AFMVOI putty Art FoOlity Perm.l <br /> III.APPLICANT INFORMATION: r <br /> NAME: �.OUrI n Y uSe 1l�� -Ihono: ?_6`! �? r ,,'I <br /> HOME ADD RE-55 IPC I171yS 4j -\Ij\f (A hlri l l <br /> City: r ive.+'ba-►'LK Stntr: C-Y'l lip: c � (n _ _C.ounty: <br /> BODY ART PRACTMONER ONLY <br /> Date or Berth: Z U Gri-der: F a- M (orde cine,) <br /> b'ertlhcat:on lytu?; orivc;I ccrrcr Cllhrr Idnnliflurtiun Nu.: _—_- <br /> Facility whirr-Body Art Services Will be Provided <br /> inn.rt rianw: -Ur��i.rYlSCtI.PP. f�FZr_W> __-. Ownar: �Vtrli'1( <br /> Addn,!r:: 3ttL W: tt/,l ry}'(Y1e.r c. <br /> Evidence or Six months of Rclated Fupe.rirnce <br /> torcity mm-4.: <br /> AJdrr-s- <br /> ServiGeYou PtQv.dEd: <br /> 5ut:_rr soi Nast?asti0 Contact tnforma;lon <br /> Sloodborno Pathogen Training:Submit Certificate L <br /> D;itrCorn:lctml t�C'(. 2�r ��� Train.0 Pruvidedti : �L�(iYG lel '1 r1t - (f?�1ri <br /> Hepatitis D Vaccination Status:Choose one and Submit Documentation <br /> 1�CErtihCation UL C0111p1.3t•_d Voctrnabon 1�Cnnt-.aind�:alr.;l t.:r M<•.I;:.el Rc.r!.c:r: <br /> Z[nLa_dratory Evident{of lmmun,ty 4[�VaLCn,diun Dctinwliun <br /> V1.FACILITY LOCATION(S):(ALtach a•_didonal Sher.;,n;rc-r;.rry) <br /> 1.BUSINESS NAME. G --F rzL,).S <br /> LC-CMU)n ndrir, 3422 [4amrr-,-A� L W y •9— tiulrr: 1 <br /> City: State: /ID: CnwitY: r-.11n <br /> 4 L <br /> ryI I <br /> Ovirtcr Conlnu: Van �lrn� <br /> 1-ay: It�G 1 (A <br /> 2.BUSINESS NAME: <br /> Lc-_ation nddrr-s; 5urte: <br /> Clay: ;l flu: Up! r:nnnty- <br /> C)wnrr/C.nntecl: I'hp��/I-0X: <br /> T'ie undcr,iyne(f herehy aplille'.for a body Art hac,hty Permit and/or PrLictiduncr RcrjhA otion ,end/ur Mechrni(hl <br /> ltid and kar Piercing Notification and agrees to operate in acwr(latir e wlth all applicable state and local <br /> rrquirernent;governing.ate body ail practices or practices governing mechanical Mutt and 0055)eor piercing, <br /> I herr-by rrr•tify that to th�brat f my knowledaa and belief the statements made herein are true and correct. <br /> S yrra:un!: � roti-- Dntr: I2- rj 1-CU <br /> Fr int Naille' ' --- L(�LlCj l'1 _ AU3 c%rt'url 7il!r. �ayG(0 rl <br /> FOR OFFICE USE ONLY <br /> P utua-r (PE; i H4--: ! i % Aulhori.ec'.`.iv(RENS): 5lw( ;,i Date Entered: <br />