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.♦ w <br />San Joaquin County 4 1868 East Hazelton Avenue <br />Environmental Health Department Stockton -3220 <br />p Tel: (209)) 4 4668-3420 <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />72- <br />1. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) y Z <br />Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing ,.. <br />Branding Permanent Cosmetics m <br />22�T NO <br />�! <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. m m N <br />ir7Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing NotiAla n <br />2F]AnnuaOody Art Facility Permit <br />Date of Birth: /oC 'a.L - 9 It Gender: I F I <br /> <br />Facility where Body Art Services Will be Provided <br />Facility Name: L© Y,a, C'T Y LAT 1005 Owner: CI F <br />Address: 6 /A A L� lJN L{ <br />Evidence of Six -months of Related Experience <br />Facility Name: ft c -r 40 S' Owner: E G <br />Address: 7_706 677 NAn /vi -E (e ( iV <br />Name and Contact <br />IBloodborne Pathogen Training: Submit CertificateD H ( PAA <br />Date COmDleted: ho -111 — td Trainino Provided bv: T N iw�rz � � <br />epatitis B Vaccination Status: Choose One and Submit Documentation <br />IMCertification of Completed Vaccination <br />2MLaboratory Evidence of Immunity <br />3MContraindicated for Medical Reasons <br />421Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: LJ YA(-r y TA S <br />Location address: <br />70 <br />7 C, <br />/\4A Pr— it LAJ Suite: t'( <br />City: <br />State: <br />- <br />C' / Zip: ef XaO 7 County: S/� ��Ur,�/ <br />Owner/ Contact: r ex5er ola-Lia <br />F <br />i_yL <br />(- ,e'T <br />Phone/ Fax: Qc • a-7/- 5383 <br />� n <br />2. BUSINESS NAME: <br />Location address: AJIA <br />Suite: <br />City: <br />State: <br />Zip: County: <br />Owner/ Contact: <br />Phone/ Fax: <br />The undersigned hereby applies for a E ody Art Facility Permit and/or Practitioner Registration and/or Mechanical <br />Stud and Ear Piercing Notification and _igrees 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 th t the best of y kn wledge and belief the statements made herein are true and correct. <br />Signature: 2 Date: Inl o <br />Print Name: 61tv KS /- (Dloularr ieTitle: ®WrtJCQ ,q W T/S 7 <br />