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San Joaquin County • 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AN <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIF CA ION R <br /> EFCFIVFD <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) 2 J 2012 <br /> Tattooing Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding Empermanent Cosmetics ENVIRONMENTAL HEALTH <br /> -- Rro 1145'-,ERVICE'S <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1®Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2©Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: Q,N� 0,-,\0,-,\ / <br /> <br /> +`� <br /> Date of Birth: 12 - - l 6 Gender: F or MM� (circle one) <br /> Identification Type: MDrivers License MOther .: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Ql1 T,+5 cD v e Owner: �_l Y1 a cc 0 h j <br /> Address: 61c1• °` <br /> Evidence of Six-months of Related Experience <br /> Facilit Name: R+Y Owner: <br /> Address: 5 1 S 6 Pac-TEC, ✓e • 5 i-IL <br /> Service You Provided: P e Y M Cal h e-vL? co 5 tvi e 6'c. <br /> Supervisor Name and Contact Information: 11 L'a1i1 ;h h vi <br /> Bloodborne Pathogen Training: Submit Certificate p <br /> Date Completed: 061 <br /> 08 12,01 Z Training Provided by: Acade- ` d C 94 Post fd, 1O.C . <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1®Certification 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 e S ,9LL_kAt Gtr S 1s1�'C5 S i GfIJ� <br /> 1. BUSINESS NAME: �Cu.J+'�- �„lr MLvl <br /> Location address: -; 8n4,':6"(_ A}✓£ Suite: l <br /> City: S�V tV-+V0 State: CA Zip: 9T2-11 County:Se'— ,7Q 6L`+lt <br /> Owner/Contact: �GV,Jv� �-+G:v+R Phone/Fax: C 2X3 <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 besot of my knowledge and belief the statements made herein are true and correct. <br /> Signature: 1/L` j� Date: (� /�- / !32 D/ Z <br /> Print Name: jRAJ& Title: <br /> f2 <br />