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San Joaquin County 1868 East Ha elton Avenue <br /> 't 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 /> r—mTattooing Body Piercing r7lMechanical Stud and Clasp Ear Piercing <br /> Branding ElPermanent Cosmetics <br /> IL REQUI ED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 19,Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: L `/ <br /> NAME: -TAQi>gN (%t17�j4Y es Phone: <br /> HOME ADDRESS: 23( -rUVZ-UST_ Email: F;qI31o4N$f'}V—(4D M&1(,.CO►M\ <br /> City: AG State: C04' Zip: 7(a County: SAnI _)0PcQQiM <br /> MEMO <br /> Date of Birth: y�G�m���� O $ Gender: M or (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: O O T1FV L, "PI G1-11 ON S D l*Q S Owner: W((,kl 1 N <br /> Address: IpOS E f Esc^oee.a AWN/ rla 2157TIs?-AEG GA 15 30 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: � <br /> D LO F L fav D0kCTlOn1S PlO �1 Owner: W L., tAU6GkT-- <br /> y s <br /> Address: `7 S & ST. T • G4 IT <br /> Service You Provided: O oo <br /> Supervisor Name and Contact Information: Wt Vt.,l A?-*1 VG 1 N F1 1 ZS 51 (o t_7 3 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: jVL11 30 2vZ Trainin Provided by: 'a G U <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 r__j Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[:]Laboratory Evidence of Immunity 4�Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Le (,o n—F-vL. PoD O�c;ri r,.A` <br /> Location address: ADS �Of}IDt�2—J Suite: 2 <br /> City: �`R- y State: CA Zip: b 3 0 County: 044 VrN <br /> Owner/ Contact: W((,l Ayvt (y[N C Phone/ Fax: �2J �ICR— 6 S7 <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/ Contact: Phone/ Fax: <br /> Tfe 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 bg t of my krLawledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Pr nt Name: FA- 3 1A-AZ CMIJ1E Title: <br /> ,t <br /> s <br /> M12 <br />