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Eco Py <br /> b f" San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tcl: (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 ®Body Piercing oMechanical Stud and Clasp Ear Piercing REI <br /> ®Branding Permanent-Cosmetics ) <br /> — ii ill <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3 MechanicaStuand Ear Piercing 11 <br /> - l Stud ClEPii <br /> � ��1fP&MENTAL HEALTH <br /> 2 LeNAnnual Body Art Facility Permit PERMIT/SERVICES <br /> 111.APPLICM INFORON. per` r' <br /> NAME: Phone: — O ltd"t�0�� <br /> HOME ADDRESS: I to KI.Zr-- vpacS AD Email: lae-Q10 <br /> CU: State: CA Zi r County: l I <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 0 Lt-(3 Gender: or IM (circle one) <br /> Identification Type: Drivers License Other Identification No.: 0 <br /> 59 <br /> Facility where Body Art Services Will be Provided e o <br /> Facility Name: 1 E- �r L3 l`AC) Owner: 03VykA <br /> Address: l C <br /> Evidence of Six-months of R ed Ex `er". nce <br /> Facility Name: Owner: <br /> r a o <br /> Address: <br /> Service You Provided: N NIT UaAE:rl CS S ROWS <br /> Supervisor Name and'Contact Information: ('• O <br /> Bloodborne Path®.gen TraLing:Submit Certificate i' Qt!J�6Q/ — <br /> Date Completed: V t! Training Provided b l' O c3 <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1loCertification of Completed Vaccination ri1Q 3®Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 1 4®Vaccination Declination <br /> IV.FACILITY LOCATION (5):( ttach addition I sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: a44 1. Suite: <br /> Ci State: r1py Zip: Count : OulT—\ <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 'tify t&s .c to the best of m Icnowledg and be' f the statements made helrc-in are true ane!correct. <br /> Signatur Date: <br /> Print Name: Title: <br /> EFOROFFICE USE ONLY e�hnw r <br /> ): Fees: Authorized by(REHS): Date Entered: <br />