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" San Joaquin County 1868 East Hazelton Avenue <br />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 definons) <br />Tattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES; Check all that apply. <br />1=Annual Body Art Practitioner Registration 3F7Mechanical Stud and Clasp Ear Piercing Notification <br />z Annual Body Art Facility Permit <br />III. APPLIC NT INFOR ATION:''^^,n� <br />NAME:ICnle �Cr <br />Phone: Gts`I ' <br /> <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Attach additional sheets 1asnecessary) <br />Date of Birth: (0 5 11 U <br />Gender: W or M (circle one) <br />Identification Type: E7q6rivers License Other <br />Identification No,: <br />Facility where dy Art Services 'll be Provide <br />FacilityName: V � <br />Owner: <br />Address: t� <br />'1 I <br />('I G7/ t! <br />Evide�nc e€SS-months of Related Experience <br />FacilityName: <br />Owner: <br />Address: <br />Service You Provided: ---- <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 3D 2 2 Training Provided Py: <br />_ <br />vlro�g DCY4Of rt-Q� <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3r"IContraindicated for Medical Reasons <br />2[=Laboratory Evidence of Immunity 4=Vaccination Declination <br />1. BUSINESS NAME: �1'1Q-n�2 \'�G�GLLI_'T� �17L <br />Location address: zlI �i Yl�l0.t�Clr1 �L1YLd <br />Owner/ Contact: Phone/ Fax: <br />BUSINESS NAME: <br />Location address; Suite: <br />City: Stale: 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 c�rtify that o�tl a st of my knowledge and belief the statements made herein are tine and correct. <br />Signature: Date: a 3 <br />Print Name: ��' _�jQ_r PX Title: L kAJ I <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (R[HS); Date Entered: <br />e7 <br />