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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. PROCEDJRES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />0 3randing Permanent Cosmetics <br />II. REQUIFED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1M4nnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2=0,nnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: AN'bRf- o/✓ecto BEC'ERR'4 'JR Phone: l i % 65- % 9// 7 <br /> <br /> <br />Cate of E rth: <br />Gender: =1 o M (circle one) <br />IdentificE =ion Type: rivers License MOther <br />Identification No.: <br />ti <br />Facility inhere Body Art ^S/erviic�es�Will be Provided <br />FacilityName: DV/LLC TAT.), SriJ(� <br />owner: Gf/STR✓� <br />Address: la -7 W AAo,W All? <br />5" tc CKT d CA 7S2 -e <br />Evident= of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service )-u Provided: <br />Su erviscr Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate T <br />Gate Coroleted: /O' l e, a 2 Training/) <br />Provided b : CA7- y wv l � c <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />l[-::J--ertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2[�aboratory Evidence of Immunity 4 =Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />L BUSINESS NAME: <br />Location address: Suite: <br />Ci -y: State: Zip: County: <br />Cwner/ CDntact: Phone/ Fax: <br />2 BUSINESS NAME: <br />1-3cation address: Suite: <br />City: State: Zip: County: <br />Cwner/ C Dntact: Phone/ Fax: <br />The unders gned 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 testify that he est of=AA <br />ledge and belief the statements made herein are true and correct. <br />Signature: j Date: /0 • 19- Z -Z <br />Print Name:P-C Atce-gien Title: <br />FOR OFFLCE USE ONLY <br />Program (PE ): j. -Ill 0 Fees: ).$G Authorized by (RENS): i M G rl Date Entered: <br />