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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205 <br />P 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 />QTattootng "Body Piercing "Mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />Moment <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />Y[EjAnnual Body Art Practitioner Registration 3[::]Mechanical Stud and Clasp Ear Piercing Notification <br />2MAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />)2e� 296/ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Facility where Body Art Services Will be Provided <br />FacilityName: Ofd Ui(IPJ TFM400) <br />((�� <br />Owner, Ic,�l"q <br />Address: 2.I , jZe f "le' ni.;w {—n. !1 <br />�2JZ . <br />Evidence of Six -months of Related Experience <br />FacilityName: 016 U'��! 0200 <br />owner: TOS% awi�tAA� <br />Address: 1 w. e4,p , t <br />f 6vq QA <br />Service You Provided: TCS,+'+ <br />O'I'L <br />Supervisor Name and Contact Informata: J ok 6k eL144 'ir— 2o�p) 3e = 9553 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: q/267;zz Training Provided by: <br />C6;k on4j tp <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity 4�Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets 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 that to the best of /mm�y�y-'knowledge and belief the statements <br />/m de/h/erein are true and correct. <br />Signature: U,u�r�.2/ //tGd Date: �(-0�I7Z�-/ <br />Print Name: Zg±�/nom i n tYL1t; Title: <br />FOR OFFICE USE ONLY <br />Program (PE): cI I iy Fees: D ISG Authorized by (RENS): ���3 Date Entered: 4// 1. <br />