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Hazelt <br /> , t San Joaquin County ia6s East Stockton, <br /> C Avenue <br /> *Environmental Health De artmentO Stockton)46 -3220 <br /> P 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 ElBody Piercing IDMechanical Stud and Clasp Ear Piercing <br /> Branding ETermanent Cosmetics LL I 3 0 2012 <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing NP ' ' MSE <br /> 2 <br /> 1KAnnual Body Art Facility Permit <br /> III. APPLICANT INFO MATION: ®® {{ �7 ( rt <br /> NAME: .. ,V Phone G / CI <br /> HOME ADDRESS: Email: <br /> Cit 1n State: Zi County: c <br /> £, BODYARIr1?RACTITIONEWONLIf, . .... <br /> Date of Birth: Gender: [E o M (circle one) <br /> Identification Type: MDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 6 Owner: vi yj 'e l\ <br /> Address: ® �' O 5 <br /> Evidence of Six-months of Related Experience <br /> / P <br /> Facilityj Name: A A) C.k__ -Mtioo Owner: &b t0la., 441 <br /> II ,\ <br /> Address: C��i�,�`� C1 r C.-� <br /> Service You Provided: <br /> e <br /> Supervisor Name'and�Cbntact Information: 9 i(? (off �� I S S— <br /> Bloodborne PathogenraTL <br /> ' : Submit Certificate a <br /> Date Completed: TrainingProvided b <br /> Hepatitis B Vaccination atus: Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> L. <br /> 2 Laboratory Evidence of Immunity 4®Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as ecessary)- <br /> 1. BUSINESS NAME: C; <br /> Location address: c <br /> c— id Suite: 'e <br /> City: State: Zip:_ ,y County: O <br /> Owner/Contact: O khwkn y 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 goverrim. safe b art practices or practices governing mechanical stud and clasp ear piercing. <br /> Signature: y ge and belief the statements made herein are true and correct. <br /> I hereby certif th t the b st'of knowledge <br /> g Date: r — �, <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY = fr <br /> Prdgram (PES Fees Author+ edx�b�t(RENS)WN <br /> Date Entered <br /> nr <br /> f2 <br />