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1 <br /> 0 San Joaquin County 0 1868 East Hazelton Avenue <br /> StoEnvironmental Health Department el: (209)kton,46 93220 <br /> Tel: (209)468-3420 <br /> �a `+ Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> 'MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION RECEIVp <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) DEC 1 1 2012 <br /> Tattooing r7Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> OBranding OPermanent Cosmetics ENVIRONMENTAL HEALTH <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. PERMIT/SERVICES <br /> IMAnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[-::]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: A n"LL w(R)Irz Phone: <br /> <br /> <br /> BODY ART PRACTITIONER UNLY. <br /> 5 Y t <br /> Date of Birth: �•L�'Sf' G� Gender: M orML <br /> (circle one) <br /> Identification Type: r7lbrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> FacilityName: / Owner: l- > '�! <br /> Address: l � lexZ <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 /> 1r--jCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: 7-11f aQc'Emy 7X�7T/!Y l <br /> Location address: 2U AlZ&,t;fAt1z Suite: <br /> City: jwwn oAl State: zip: 9s1P2 County:1V/1196U//1 <br /> Owner/Contact: ,/Ffff/Z11Z, NUv i./!1R Phone/ Fax: ?lX/-�/S/• #3-/16 <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: 12-Z/-j2 <br /> Print Name: X011416/ LX&ItZ7 Title: /QjpmT <br /> FOFFICE USE.ONLY, <br /> R O <br /> Program (PE) Fees '__ AutFonzed.'by.(I2EHS) Date Enteredc- <br /> f2 <br />