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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: Check all that apply (see back for definitions) <br />"Tattooing LjBody Piercing L..JMechanicai Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1MAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2[Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Att <br />Date of Birth: IV 110191Gender: <br />F or MM (circle one) <br />Identification Type: CPDrivers License MOther <br />Identification No.: <br />Facility where Boody Art Services Will be Provided <br />FacilityName: 4P Ses$Q gnu ( <br />11 nn <br />Owner: Q IK fgndlio <br />Address: °if 23;3 I'M FIC WV Jte <br />U014 <br />Evidence of Six -months of Related Experience <br />FacilityName: PreTT 01 ACID 10 <br />p <br />e R(A Owner: r -IQ u <br />c <br />Address: 2-3r3 ci-nve of <br />m ATeo C �� <br />Service You Provided: <br />�Y,t <br />NILQ <br />Supervisor Name and Contact Information: W&L <br />KYOW <br />- q lD ` $2& L 3 21i <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: S I ) it 1 1 I Training <br />Provided by: OW Q 1 <br />Hepatitis B Vaccination Status: Choose One and <br />Submit Documentation <br />1MCertification of Completed Vaccination <br />3QContraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity <br />4®Vaccination Declination <br />ach <br />as necessary) <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 <br />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 th t e of my knowledge and belief the statements made herein are true and correct. <br />Signature: Date: 3I 2rl �2 <br />Print Name: �Q,j1,`�� Title: (oMIL TO op hMS . <br />FOR OFFICE USE ONLY te,�r��� <br />Program (PE): �fl LD Fees: �j� Authorized by (REHS): a�t,v- � � �++�uL� <br />mate Entered: <br />