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rr <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue <br />Stockton, CA 95205 <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 />r'lTattooing ®Body Piercing m1plechanical Stud and Clasp Ear Piercing <br />Branding MPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1®Annual Body Art Practitioner Registration 3[DMechanical Stud and Clasp Ear Piercing Notification <br />2MAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: ��C\UCS.1U� �Q'Q-MGh(7t Phone• (201 i(SI�OI�S <br /> <br /> <br /> <br /> <br />Date of Birth: <br />Gender: F or M (circle one) <br />Identification Type: Drivers License MOther <br />Identification <br />Facility where Body Art Services Will be Provided F}Vp i:JGfT�,iE <br />'Facilit Name: Q <br />Dir AM Owner: <br />Address: lull E liN W <br />Evidence of Six -months of Related Experience <br />/ 1N46G U"ERP- <br />Facilit Name: 6 <br />C6m RM Owner: aim Mhom <br />Address: SNL C'" WQg2t- A <br />Service You Provided: rl CKC 1 N <br />Supervisor Name and Contact Information: <br />L IZTC q - q33-/1$1 <br />Bloodborne Pathogen i r i� i g: Submit Certificate <br />Date Com lete�• f Training <br />Provided bE, C&fl"1n4 MAYk4if, <br />Hepatitis B Vaccination Status: Choose One and <br />Submit Documentation <br />1r7Certlfication of Completed Vaccination <br />3F]Conraindicated for Medical Reasons <br />2[=Laboratory Evidence of Immunity <br />4 accination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />Location address: SNL E. WQt(I4b Rye `I <br />Suite <br />Owner/ Contact: JafRft dN0jjW!k IF) d� sICTGf Phone/ Fax: 1`110c1Alifth <br />� 227 $ $ f <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 be of my kn dge and belief the statements made herein are true and correct. <br />Signature: _ // 0� Date: <br />Print Name: CI(11��SQ CQam O Title: <br />FOR OFFICE USE ONLY ,f 1 <br />Program (PE): \IIIb Fees: j ISL Authorized by (KERS): Date Entered: <br />