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• San Joaquin County 0 1868 East Hazelton Avenue <br /> Environmental Health Department <br /> StocktonCA, <br /> P 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. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding aPermanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1[DAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2EZ]Annual Body Art Facility Permit <br /> 111.APPLICANT INFORMATION., <br /> NAME: C(� �� zi ��j� S Phone: -70 Z <br /> HOME ADDRESS: /(1 p 8 A/, e,'7 )Ck-701V 5'r- Email: t►'fSL{9 lam/ <br /> city: 'T pr --roState: ce, Zip: 9 "'ZL) County: ;r�vt cs�z rJ "�a�oJ'C`ah <br /> Date of Birth: (p 7i Gender: M or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided _ <br /> Facility Name: {e r DU Owner: Ce CZ <br /> Address: -3e i,,A <br /> _J32 5 e 10 Ce- - 95--2—Q'S <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 Train!n :Submit Certificate VIA Date Completed: Z TrainingProvided by: " ` G`yt <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> IMCertification of Completed Vaccination 3MContraindlcated for Medical Reasons <br /> 2[DLaboratory Evidence of Immunity 4EO accination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Q ,)4 7v-t;(-- <br /> Location address: 9 j ` 4- `7t Suite: <br /> city: C TJ State: C11 Zi 9 v Count ac V j V,%., <br /> Owner/Contact: C"DeP FF -i16� Phone/Fax: 8 <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 No 'fica ion and agrees to operate in accordance with all applicable state and local <br /> requirements governing fe od ractices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify hat he es of my nowledge and belief the statements made herein are true and correct. <br /> Signature: Date: �J f <br /> Print Name: Title: fn f� <br /> e <br /> *" r, <br /> FOR OFFICE USE ONLY' -M l <br /> Program(PE). r id by((tEHS) rs+ Datfe�ed r <br /> If2 <br />