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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205 <br />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 PERFORME Check all that apply (see back for definitions) <br />Tattooing MBody Piercing Mechanical Stud and Clasp Ear Piercing <br />0Branding Permanent Cosmetics <br />II. REQUI 'ED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />I nnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2[:]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATTIION: e 1 1 7 <br />NAME:(`. C C_ G�'�:I�c► ' /'`"�ta('l1�tC�� Phone: ` S` �� �2 <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth; oall Z.S/ Gender: or MM (circle one) <br />Identification Type: r77fDrivers License Mother Identification No.: <br />Facility where Body Art Services WillAbeProvided <br />Facility Name: >✓.S� l T OkZ Owner: Sl �lG i <br />Address: 239 , lv ' <br />Evidence of Six -months of Related Experience <br />Facility Name: Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: %/2--3/2-3 Trainin Provided b : IJ iOl0� i GS <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3EContraindicated for Medical Reasons <br />2�Laboratory Evidence of Immunity 4 Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME, <br />Location address: Suite: <br />City: State: Zip: County: <br />Owner/ Contact: 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 th t to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature:. Date: <br />Print Name: _1_r' neAjr ' C ,�;%%h i>',,. L Title: fi e—_- <br />FOR <br />-c <br />FOR OFFICE USE ONLY <br />Program (PE): `l ! c. Fees://r „/ Authorized by (RENS): r;.,j, , , f. r# Date Entered: <br />