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San Joaquin County 1868 East Hazelton Avenue <br /> CA <br /> l 4U Environmental Health Department Stockton , 463220 <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 /> I . PROCEDUR <br /> ng <br /> ID Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES : Check all that apply . <br /> IMAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2E] Annual Body Art Facility Permit <br /> III . APPLICANT INFORMATION : <br /> NAME : Suwichada Kanmaneekun Phone : 209-373-9473 <br /> HOME ADDRESS : 2504 Goldsmith Way Email : nraughmoob77@yahoo . com <br /> City : Stockton State : CA Zip : 95212 County : San Joaquin <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth : 06/ 16/87 Gender : M or MM ( circle one ) <br /> Identification Type : Drivers License Other Identification No . : <br /> Facility where Body Art Services Will be Provided <br /> Facility Name : Salon Allure & Spa Owner : Shandra Som <br /> Address : 702 Porter Ave . , Stockton , CA , 95207 <br /> Evidence of Six- months of Related Experience <br /> Facility Name : Dala Beauty Brows Bar Owner : Sunaree Kanmaneekul <br /> Address : 8183 University Ave . NE Spring Lake Park , MN 55432 <br /> Service You Provided : Eye brows tattoo , lip , eyeliners <br /> Supervisor Name and Contact Information : Sunaree Kanmaneekul Cell : 612 - 770-2940 <br /> Bloodborne Pathogen Training : Submit Certificate <br /> Date Completed : 4/ 15/22 Training Provided by : Biologix Solutions <br /> Hepatitis B Vaccination Status : Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2 [= Laboratory Evidence of Immunity 4[1]vaccination Declination <br /> IV . FACILITY LOCATION ( S) : ( Attach additional sheets as necessary ) <br /> 1 . BUSINESS NAME : S tid ✓ F <br /> Location address : Suite : <br /> City : State : Zip : County : <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 that. t he best of my knowledge and belief the statements made herein are true and correct. <br /> Signature :. Date : 8/31 /22 <br /> � <br /> Print Name : Suw— I d Kanmaneekun Title : <br /> FOR OFFICE USE . ONLY <br /> Program ( PE ) : f . � Fees : �_ Authorized by ( REHS ) : , Date Entered : <br /> f2 <br />