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San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95105 <br />Environmental Health Department Tel: 1209) 468-3420 <br />Fax: ;209) 464-0738 <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 />=Branding =Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1t!!�Annual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br />2=Annual Body .ort Facility Permit <br />III. APPLICANT INFORMATION: ,[�\ <br />NAME: \ \) ���Q� �C . Phone: C?C�`1 <br />t <br />HOME ADDRESS: �)2, �,,f��\ S� hh Email: C(J <br />Ci -.v: _V\Or k G n State: CZ Zio: Countv: .\Gly n A(7Jl A'i (\ <br />Date of Birth: G <br />Gender: M o M (circle one) <br />Identification Type: Drivers License Other <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: L ( <br />1 t to Owner: <br />Address: I .`� � V � <br />C <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service "ou Providec: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathcgen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r--ICertificaticr of Completed Vaccination 3[:DContraindicated for Medical Reasons <br />2MLEboratory Evidence of Immunity 4['�:]Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />Location address: �� L �-��C �� Suite: <br />city: S.Acc r' State: C -A� Zip: County:—S-A <br />Owner/ Contact: Phone/ Fax: <br />2. BUSINESS NAME: <br />Lccation 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 govern -ng 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: \ \ Date: <br />Print Name: �;W j`C )�`j,C r Title: <br />FOR OFFICE USE.ONLY <br />Program (oE): �. j�I (� Fees: 1 Authorized by (REHS): Date Entered: <br />