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San Joaquin County 1868 East Ha2elton Avenue <br /> �\) 95205 <br /> Environmental Health Department Tel: (209)Stockton CA 46E-342C3420 <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 definitions) <br /> Tattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> CBrancing =Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1=Annual 3ody Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual 3ody Art Facility Permit <br /> III.AP�LLC`A y,NT INFORMATION: �y T � <br /> NAME: «h e 1. �/��.A �r[�l�l Phone: /0 '- !G �J <{c <br /> HOME ADD2ES3: r6 v Al .,4-- Email: Ve/ <br /> City: .'cc4k" State: CA Zip: q.5130 County: 54,A-i Jr C1V <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 1j Gender: (r'_Fj or MM (circle one) <br /> Identification T•/pe: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided )� <br /> FacilityName: L 11 (cl Y U L/ /G(f,46,6, Owner: <br /> Add-ess: �4� 1461 i <br /> Evidanc2 of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Add ass: <br /> Service 1'ou Prcvided: <br /> Supervisor Name and Contact I-iformation: <br /> Bloodbcrne Pathogen Training: Submit Certificate <br /> Date Competed: ieC, + <br /> 2 Trainin Provided b L {�Uc�cl <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1M5prtifilcation of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[21'_aooratory 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/Cortact: Phone/ Fax: <br /> 2. BUSINESS NAME: <br /> Loca`ion address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/Fax: <br /> The undersigied h?reby 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 /> requiremerts go✓e-ning 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: !e5 Date: Z✓dJ_6. 3 <br /> Print Name: V Kl- Title: <br /> FOR O=FICE USE ONLY <br /> Progran (PE): q'10 Fees: 0164 Authorized by(REHS): 66INCrI� Date Entered: <br /> 7. If2 <br />