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—.� San ]oaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />ins? 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 MBody Piercing 71mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES; Check all that apply. <br />1MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2MAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION:, ��(� \ l ,j�l/� �I�I �/ % <br />NAME: M I XA I '" Phone: (0 <br /> ).( <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: I 9 % Gender: F or M (circle one) <br />Identification Type: Drivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: Lk A t: Owner: <br />Address: C <br />Evidence of Six -months of Related Experience <br />Facility Name: C_ L Owner: NI y1c) <br />Address: q 1 CH - <br />Service <br />H - <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1=Certification of Completed Vaccination 3= ontraindicated for Medical Reasons <br />2=Laboratory Evidence of Immunity 4 Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />Location address: C 1 n SI Suite: <br />Cit 1 tQo_ State: C Zip: J �^ � County: <br />Owner/ Contact: �. 1Yl l)7 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 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 he ein are true and correct. <br />Signature: 6i Date: <br />Print Name: M 1 (11A u "LQTitle: <br />FOR OFFICE USE ONLY <br />Program (PE); 411 (0 Fees: �C/,S � Authorized by (REHS): 661N[sN Date Entered: <br />2 <br />