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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> R' Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> •MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION RE IVED <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) DEC 112012 <br /> 12JTattooing ®Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics ENVIRONMETALHEALTH <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. PERMIT/SERVICES <br /> IAnnual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: Y461LIFL L&C21Lfz Phone: <br /> HOME ADDRESS: /� cCJ'�/� Email: <br /> city: J �K1�'!✓ State: (pIQ Zip: County: <br /> PRACTITIONER ONLY-'.k LL; <br /> Date of Birth: Gender: F or (circle one) <br /> Identification Type: Drivers License Mother Identification No.: r <br /> Facility where Body Art Services Will be Provided <br /> Facili Name: MIZ f'' ' Owner: 6 'f f l-`I /' <br /> Address: OV64"24 2C7Z <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: Training Provided by: <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3®Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4®Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: ra &Tz";2-M/NW-P <br /> Location address: 2�Z Suite: <br /> City: MT/V State: (35i Zip: County:JXd1/ <br /> Owner/Contact: ,/Ffa1?Lj12 Phone/Fax: 1l�-V 5/ /L <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 that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: — Date: j1•lI i2 <br /> Print Name: r,41VbX) t/.�;�'Wt2 Title: A00- <br /> FOFt OFFICE USE�ONlY <br /> Program (PE) Fees Authonzed by(REHS) _ Date Entered - <br /> Tif 2 <br />