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San Joaquin County 1868 East Hazelton Avenue <br /> r '`. Stockton, CA 95205 <br /> 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 /> I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> <br /> REQUI ED REGISTRATION, PERMIT, OR NOTIFICATION FEES; Check all that apply. <br /> 1[2]Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: Nr r S s oL'Nk,ry <br /> NAME: 3b '1 UhlyfVT Ci-Y7Q , Phone: 2 _ ,Zy CAC) 419HOME ADDRESS : Email : dhridiprie(A 1J4 YSe <br /> F <br /> qi"Vi, Ly ls"'I <br /> CI Cr State: L ZIP : LC6 Count <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth : C\C111 Gender: Imormi (circle one) <br /> Identification Type: Drivers License MOther Identification No. : 6 5 <br /> Facility where Body Art Services Will be Provided C <br /> FacilityName: ,- K S Owner: hl S' C\ 11123 <br /> Address: +r" nck oist65 <br /> Evidence of Six-months of Rel ed Experience C <br /> Facility Name: 5�? Nu-Ow"\ S Owner: S\ e <br /> Address: 1AUD <br /> Service You Provided: <br /> Su ervisor Name and Contact Informati n : <br /> Bloodborne Pathogen Training : Submit Certificate ' <br /> Date Com leted: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentatio <br /> 1MCertification of Completed Vaccination 3[=IContraindicated for Medical Reasons <br /> 2[=]Laboratory Evidence of Immunity 4rVaccination Declination <br /> IV. FACILITY LOCATION (S): (Attach additional) sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: ZVrji- % V\AS fQ < � Sulte : <br /> Ci : C{,K\r0✓) state: N Z( R:.]1 Coun : t,( t ✓� <br /> Owner/ Contact' Ask f✓\k (Ok Phone/ Fax: <br /> 2. BUSINESS NAME: <br /> Location address: Suite : <br /> City: State: Zip; County: <br /> Owner/ Contact: Phone/ Fax: O 6 V <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 t the best o r y knowledge and belief the statements made herein are true and correct. <br /> Signature: - Date: <br /> Print Name : ,�L��th L..0 i k4sss 7 Title: yit C( If yss% <br /> FOR OFFICE USE ONLY <br /> Program (PE) : Of if 0 Fees: 6 ( 5 2 Authorized by (REHS) : A lij &&1 Date Entered : <br /> 2 <br />