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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA 95205 <br /> P 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. PROCED RES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> 9Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUI ED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT <br /> INFORMATION: <br /> NAME- <br /> '2001 <br /> nI oI <br /> NAME- \�Wv--,i%e��l/'�� Phone: LD- 1 � 10E -2501 <br /> HOME ADDRESS: L17i/1..7 IA (i� Email: Sa7,Cj ITO T&TT 2 01 I'1A 1 L' <br /> City:'Oroo�(O State:( A Zip: 152 County: �N 7oftno <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 1 ��<� Gender: F o M (circle one) <br /> Identification Type: rADrivers License Other Identification No.: CO�( rj <br /> Facility where Body Art Services Will be Provided �� <br /> FacilityName: 1 N 1__ GA 1 TT Owner: L <br /> Address: 16'0\ N NTE CA 01 S Z <br /> Evidence of Six-months of Related Experience r, <br /> FacilityName: 1 1 T �cr.., Owner: 7t�v Iqs <br /> Address: 5\5 D UWS9-"09ZqN SS 1 <br /> Service You Provided: I°t T00 <br /> Supervisor Name and Contact Information: 0 C T m 00li' S2,I- 0(0Z:0 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed:I\10 1 Z'0Z3 Training Provided b v V oNj <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MCo traindicated 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: 1 N IL CIA 1 oV-T <br /> Location address: 1'°I N HONT 6R ST Suite: <br /> Ci v[0(+ foto State: CA Zip: g520 Z county: StM'I 3p <br /> Owner/ Contact: EP CSorJ to kRYPuNE!'.i-tl 1 Phone/ Fax: Z)CFI-qSl — 1151011 <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 certi t to the t of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: 11 11� I ZoZ3 <br /> Print Name: t 4'Sft7 Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): 0(110 Fees: 40 //„2 Authorized by (RENS): 6flt�tf ca Date Entered: <br /> f2 <br />