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San Joaquin County 1868 East Hazelton Avenue <br /> 95205 <br /> Environmental Health Department Stockton, CA <br /> P Tel: (209) 468-3420-3420 <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 PERFORMED: Check all that apply (see back for definitions) <br /> [Z]Tattooing Body Piercing QMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> Y[EjAnnual Body Art Pract <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> -5,0oo Owner. Lc vpq <br /> Address: 530 0, j2e�-rffei yY).;W )--/2, A <br /> Evidence of Six-months of Related Experience <br /> m 1 <br /> FacilityNae: 016 � ( '0 U' 0 owner: <br /> Address: I w, 40 j A <br /> Service You Provided: T&++9 G:il <br /> Supervisor Name and Contact Informatbtf: J oS,k AI44_� 20�p) 39s= 9 53 _ <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 3 /•2. 72, Training Provided by: C64w Pn4je, <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4�Vaccination Declination <br /> IV. FACILITY LOCATION <br /> /(1S): (Attach <br /> /additional sheets asnecessary) <br /> 1. BUSINESS NAME: `�f..C� V��i Y,e, C/'IICJo ',, <br /> Location address: 6.Z V4?1 ,�1e rna4v 1 k47, Suite: <br /> City: d State: 6A Zip:J E'w`` 2 County; <br /> Owner/ Contact: JQ � Phone/ Fax: C20J 395 7 -7� <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 that to the best�of/mm�yy�-IVtowledge and belief the statements <br /> /m de/herein are true and correct. <br /> Signature: U,u��cr�.2/ I/�TGd'� Date: <br /> Print Name: zg±�jn- (l- tYL>'[: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): cI I I u Fees: �P �SG Authorized by (REHS): qe) J> Date Entered: 7 �2-Z <br /> If2 <br />