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San Joaquin County 1868 East Hazelton Avenue <br />W tto Environmental Health Department Stockton, CA 95205 <br />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 />2. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />=Tattooing LjBody Piercing L.JMechanical Stud and Clasp Ear Piercing <br />=Branding ff1permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1r7jAnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br />2=Annual Body Art Facility Permit <br />III. APPLIC'//ANT INFORMATION: <br />NAME: L4AV)nC� "lOeer Phone: (poq)V216Ll1b9 <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary <br />Date of Birth: 0�1 I Ob t IOM7 <br />Gender: I F or rIF1 (circle one) <br />Identification Type: r7lDrivers License MOther <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: QregmSC Owner: <br />Address: 26WLI- W hOrnmer L 't F <br />e '1S 21 cl <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Com feted: 0 q %(JZZ Training Provided by: Ot o IQ 1 5o l., [ton <br />Hepatitis B Vaccination Status: Choose One and <br />SFACertification of Completed Vaccination <br />2MLaboratory Evidence of Immunity <br />Submit Documentation <br />3r'lContraindicated for Medical Reasons <br />4Mvaccination Declination <br />) <br />1. BUSINESS NAME: �✓2Arr5CcnFe �i✓'�wS <br />Location address: L W Ham me r I -A lJ YNi L 1- Suite: J") I F <br />City: 5{cY,F'{t]'� State: Cl'c. Zip: 9152 County: Sun loayuin <br />Owner/ Contact: FD• Phone/ Fax: lCiyo) �I t5 &-I O ) <br />2. BUSINESS NAME: <br />Clty: State: Zlp: 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 certify1t at to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: 1 �— Date: 03 I11 I toss <br />Print Name: I4C4G nrta V�AMPC Title: <br />OFFICE USE ONLY <br />cc• <br />3m (PE): NII() Fees: i 5 z Authorized by (REHS): Date Entered: <br />