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4D, CA San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department <br />Tel:Stockton <br />468-349520520 <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 OBody Piercing Omechanical Stud and Clasp Ear Piercing <br />ED Branding C2Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: ((�'ggV�� <br />NAME: S. P�-CCA D <br />Em <br />City: State: C Zip: -IV)7J County: . &-LLICy v <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: <br />circle one) <br />Identification Type: Drivers License MOther Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: DSS U <br />Owner: <br />Address: 9363 pKtn <br />STbGKQ)tj GEF A 1 <br />Evidence of -Six -months of Related Experience <br />Facility Name: <br />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:mstq�ED.ls <br />Location address: 2 �j �i`VE Suite: <br />City: State: G Zip: county: S t� <br />Owner/ Contact: �Qt� CSE 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 practicesor practices governing mechanical stud and clasp ear piercing. <br />I hereby certify tkno edge and belief the statements made herein are true and correct. <br />t o t t f my <br />Signature: Date: <br />Di---( U3l tq <br />Print Name: E t\ E ` w Title: <br />FOR OFFICE USE ONLY -p I> 4- <br />Program (PE): y1 I' Fees: 23� Authorized by (REHS): 3 Date Entered: �I � /I <br />