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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department 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. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> ©tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> =Branding [D15'ermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> I nual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III. APPLICANT <br /> \INFORMATION:NAME: 14 J-4�l <br /> SLY(�V�1� V� Phone:C�rV l��Q L_ lJ <br /> L 5�. s + o ot� / <br /> HOME ADDRESS: �� \!y \ I b k-u'1 �l)`� may - c17 itt�I ,c'Z IR il-�l�B���(o O� <br /> City: T State: Zip: 9 Coun co-1 <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 1,2 Gender: rij or M ( (circle one) <br /> Identification Type: Drivers License Other Identification No.: F-Z d <br /> Facility where Bod Art Services Wil be Provided <br /> Facility Name: 1 i� _ J T' U Owner: <br /> W. <br /> Address: . /± 114- <br /> Evidence of Six-months of Related <br /> ^x-perience ] _, /SZQ <br /> Facilit Name: �- l7 -4 S' S7_" Owner: / <br /> Address: ik) .O 6 ��� <br /> Service You Provided: iv�eCl/ 'C b <br /> Supervisor Name and Contact Information• _ 4-// 0 12 ZD9' �- <br /> Bloodborne Pathogen Training: mit ertificate T <br /> Date Completed: Training Provided by: <br /> Hepatitis S Vaccination Status: Choose One and Submit Documentation <br /> 1�7rcertificatlon of Completed Vaccination 3Qcontraindicated for Medical Reasons <br /> 2[-::]Laboratory Evidence of Immunity 4[=Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets asnecessary� i <br /> 1. BUSINESS NAME: S ✓v <br /> Location address: V vy LA LS Suite: C) <br /> City: S G State: Zi : fl, r , county: _-S- <br /> ooun : ,S ✓/l Jo�'%1 VL41 <br /> Owner/Contact: _ �-t�•I/19I l n� --t. Z Phone/ Fax: �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 that to th aL�ny knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: \ 1 I l9 1i-`j <br /> Print Name: z�r Z Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(REHS): Date Entered: <br /> If <br />