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i San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> y <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> 1.PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> ®Tattooing ®Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding aPermanent Cosmetics <br /> II6tEQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1®Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: ( <br /> <br /> <br /> <br /> <br /> Date of Birth: - (o Gender: F o M (circle one) <br /> Identification Type: rmDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facilit Name: .- Owner: LN-6'r a- <br /> Address: \ - UC k (S <br /> Evidence of Six-months of Related Experience <br /> Facili Name: Owner: V<C�c f <br /> Address: N,, 0, <br /> Service You Provided: g..r 4z-"n <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 E]Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[DLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: T�'Uz <br /> Location address: 3Fe.c- V"k , Suite: <br /> City: Seo c. L <br /> totr� / State: �o. . Zip: g52es Z_ County: <br /> Owner/Contact: t chi i Gvf Phone/Fax:,{a 6`1? jt/6 - 06 92 <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 t t the est of my knowledge and belief the statements made herein are true and correct. <br /> Signature: - Date: <br /> Print Name: [Ji cfi�l �� Title: <br /> f2 <br />