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San Joaquin County 1868 East Hazelton Avenue <br /> k Department Stockton)CA -3220 <br /> Environmental Health De <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 ►fff�}}RR���� <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) v �D <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing FEB0 <br /> Branding -Permanent Cosmetics CD 4 2120 <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. pERNflT SIVT/�L HATH <br /> i®Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing NotificationER�CES <br /> 21KAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> ON: <br /> NAME: '7-a ',51 Grech Phone: c2oq ��-�`,��^�� <br /> <br /> State: CA zip: f &5 County: S" LA7 <br /> 1 <br /> Date of Birth: 9-0— f Gender: Mr M (circle one) <br /> Identification Type: 01Drivers License MOther Identification No.: <br /> Facility where Body Art Se ices Will be�Prroovided y� _ <br /> FacilityName: i1 ��. IC ) rJ1 l�C��1J�` owner: I CLC1 Sl (3 <br /> Address: 1 l`i (J - �J: d� <br /> Evidence of Six-months of Related Experience <br /> FacilityName: >S? % /S0 Scaka %4110S Owner: ��ICtC�O <br /> Address: �2- <br /> Service You Provided: <br /> Supervisor Name and Contact Information: _ Z <br /> Bloodborne Pathoge Training: Submit Certificate , <br /> Date Completed: ® <br /> Training Provided b b0 Doi � c.UIU11 <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: 1 A Suite: <br /> City: State: Ch Zip: ,R) County• ]cm joGn-V,n <br /> r— <br /> Owner/Contact: 1(�i 1\Shu Uri en Phone/Fax: o�()q- ��=Cy j-] <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 tha to the bejt of my Ynpwledge and belief the statements ma4e her in are true and correct. <br /> Signature: Y6 C Date: <br /> Print Name: ] �.t�?/ ry/(��j Title: <br /> WV­ <br /> 2 <br /> f2 <br />