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San ]oaquin County 1868 East Hwelton AVeroe <br /> Environmental Health Department n,u964 <br /> Tel <br /> ' (20(209)468 342020 <br /> Fax:1209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> 7 <br /> OCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing <br /> Body Piercing OMechanical Stud and Clasp Ear Piercing <br /> a Branding Permanent Cosmetics <br /> REQUIRED REGISTRATION, r <br /> IT OR NOTIFICATION FEES:Check all that apply. <br /> 1PERM <br /> ®Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification <br /> 24Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: (' <br /> NAME: RV E Phone: 2 -423-OC3 <br /> HOME <br /> "�RESS 4 fin <br /> D LRN Email JLOM <br /> _ • �F2SON State:Q A zlp:o County: U <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 101 <br /> Gentler: or M (circle one) <br /> Identification Type: PlDnvers License MOther Identification No.: Y30(6133I0 <br /> Facility where Body Art Setvirns will be Provided p <br /> Fadli Name: K NRMi-LE @1E %"O Owner:vAFiVLEI H V 1N <br /> Address: } ULVTS ME cwac TOGK. 1 C Q 2o <br /> Evidence Of Six-months of Related Experience ��,r� <br /> Facili Name: R(.Q6p Syc\N IM MY) S1-liU Owner: ( �-AV E <br /> Address: ) 22 OA A pi O CA9 8\ <br /> Service you Provided:TMI Q !t��l Supervisor Name and Contact Information: ELIQ Vk, ql - -Z-1Oq <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Cam feted: \1 1 .'15 Trainino Provided by: Q 1J1 <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1[]6Ce1tification of Completed Vaccination 3MContmindicated for Medical Reasons <br /> 2[:3Labomtory Evidence of Immunity 4[=IVaaination Declination <br /> IV. FACILITY LOCATION (``S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME:�TIF `T'lT"11`�\�LI.FA ICI MFi�H�� <br /> Location address474 W `{Oy__VTS AVE Suite: r <br /> City: ST00 T N State: Cf\ zip: g570'i' County:SPN 1VAQ\ AtA <br /> Owner/Contact:S HAW NA M 41NN1N 6 Phone/Fax: 202\-352,-G 32) <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�f body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that t of y knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: 11� Ig��Tj <br /> Print Name: AM-F-k2 QQi,M0%;TA Title: QWt�tER <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(REHS): Date Entered: <br /> tz <br />