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San Joaquin County 1868 East Hazelton Avenue <br /> rte _ ., Stockton , CA 95205 Environmental Health Department 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 /> iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillilliillillillillillillilliillillillillillillilliillillillillillillilliillillillillI <br /> I . PROCEDURES TO BE PERFORMED : Check all that apply ( see back for definitions ) <br /> ® Tattooing ® Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II . REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES : Check all that apply . <br /> 1 ® Annual Body Art Practitioner Registration 3a Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 ® Annual Body Art Facility Permit <br /> III . APPLICANT INFORMATION : <br /> NAME : Phone : ()Vi) � IDG ' � � 310 <br /> HOME ADDRESS : Email : (I (lyrjw(jjj ,'r9P Q d (11M <br /> Cit State : ti 'C <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth : Gender : or FR1 ( circle one ) <br /> Identification Type : JWDrivers License MOther Identification No . : <br /> Facility where Body Art Services Will be Provided <br /> Facility Name : T'Ifurl OA <br /> Owner : &Iva <br /> Address : ImClSoll Al LaLull CA , <br /> Evidence of Six- months of Related Experience <br /> FacilityName • _ ' m S Owner : (- � <br /> Address : 35t <br /> Service You Provided : TOWWS I 7 <br /> Supervisor Name and Contact Information : <br /> Bloodborne Pathogen Training : Submit Certificate <br /> Date Completed : f �/ Training Provided by : � ( i <br /> Hepatitis B Vaccination Status : Choose One and Submit Documentation <br /> 1F7Certification of Completed Vaccination 3 = Contraindicated for Medical Reasons <br /> 2 = Laboratory Evidence of Immunity 4 ® Vaccination Declination <br /> IV . FACILITY LOCATION ( S ) : ( Attach additional sheets as necessary ) <br /> 1 . BUSINESS NAME : <br /> Location address : Suite : <br /> City : State : Zip : County : <br /> Owner/ Contact : 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 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 gover safe body art practices or practices governing mechanical Stud and clasp ear piercing . <br /> I hereby certify tha to est of my knowledge and belief the statements made herein are true and correct. <br /> Signature : Date : no <br /> - I t�o <br /> Print Name : � � (/� V� Title : '= t _ <br /> FOR OFFICE USE ONLY <br /> Program ( PE ) : Fees : Authorized by ( RENS ) : Date Entered : <br /> if 2 <br />