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^'''"x San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> 04'i.t.0 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 MBody Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding MPermanent Cosmetics <br /> II. REQUIR D REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i nnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMA�TIOON: <br /> NAME: ✓!j� ///��� !" II�� Phone: pZQ�j'a 018-If_T 09_-7 <br /> HOME ADDRESS: S&N 1��Ci�y-&L MoDr--�• Email:�arkchao_ -Ivk,'o hole6�2*Alliw •e*w" <br /> .City: State: zip: County: Scvk v i <br /> . 35 .. ���BCDYARTRA�TTfIONEIR' NL1' .. _ .F ; a_ >- �, <br /> Date of Birth: �l�f O Gender: F or M (circle one) " <br /> Identification Type: MDrivers License 000ther Identification No.: 2011-7 5 <br /> Facility where <br /> /B�Jpdy A(� (IMV(2, <br /> Services Will be rovided <br /> Facilityv Name: r � V(2, PlL <br /> 00 Owner: <br /> Address: ?-- W xly- <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: (Ne£ Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4Z-Vaccination Declination <br /> IV. FACILITY LOCATION <br /> �J(S):(Attach additional)sheets as necessary) <br /> 1. BUSINESS NAME: �Z /li/Q <br /> Location address: 117 C A' Suite: <br /> Cit State: Zip: R t Count 491 fi i <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 est of my knowledge and belief the statements made herein are true and correct. <br /> Signature: t W e bDate: Q Z�! Wr?, <br /> Print Name: Title: <br /> s <br /> 2 <br />