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San Joaquin County 1668 Ean Hazelton Avenue <br />CA 9 <br />_ Environmental Health Department Stockton, 468-344 -32 <br />P0 <br />Tel: (209) 4620 <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 [DMechanlcal Stud and Clasp Ear Piercing ,y <br />Branding CETPermanent Cosmetics M <br />II, REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />IMAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2 ,/ Annual Body Art Facility Permit <br />d <br />III. APPLICANT INFORMATION: <br />NAMEvrAa,S'Ctftnl -CLrJ'RaOcT_ Phone:-rt4•q^L6' 3753 1 <br /> .•,. <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />2. BUSINESS NAME: <br />Wcation address: Suite: <br />City• State• 21p• 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 best of my knowledge and belief the statements made herein are true and correct. <br />Signature: C Date: ,y.1Iml� kZZ <br />Print Name: ,nnnn ttv Irkinosy1 u- Title: (-In"by Q. <br />FOR OFFICE USE ONLY <br />Program (PE): _ T-"aes: _i�m_--_ Atithurized by (RENS): <br />Datc Entered: <br />i <br />