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San Joaquin County 1868 East Hazelton Avenue <br /> CA 95205 <br /> Environmental Health Department Tel; (209)Stockton3420 <br /> P 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 Mmechanical Stud and Clasp Ear Piercing <br /> =Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1E�jAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: n <br /> NAME: � � R &H,&i, (�LwY Phone: 200, —kO2 <br /> HOME ADDRESS: 7339 a o4e ci Lei. Email: o.^ O (A a{ft <br /> city: 5Focy--tov) State: Zip: (AGZO:e County: r7nn _>'r,Q in <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Mov. 7 00 2- Gender: rTj or M (circle one) <br /> Identification Type: rulDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided'� ��t1 __ <br /> Facility Name: r i C.. l E dUr, Owner: /Yr10 � f�Aan <br /> Address: 1 'c " E'Sca(onCA C(5.520 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: lirs J r <br /> .0 i& ''`` ,AI Owner: A,� �rc ��c�urQ <br /> Address: 1 ' c-�/+'" 57-0 <br /> Service You Provided: ',n USE <br /> Supervisor Name and Contact Info ation: /\,nrC,>\rjcyA <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: E-15-25 Training Provided b : tea' %C- <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> I=Certification of Completed Vaccination 3EContralndicated 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: <br /> Location address: Suite: <br /> _City: State: Zip: County: <br /> Owner/Contact: Phone/Fax: <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 my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: 2-5 <br /> Print Name: �- 1 <br /> G� Title: _ fa\iC1bvW <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (REHS): Date Entered: <br /> 1f2 <br />