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01". <br /> San ,OaQUin County 1868 East Haz ton Avenue <br /> 40 <br /> Stockton,CA 95205Environmental Health Department 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 /> attooing ®Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding ®Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> lEnAnnual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT)INFORMATION: q <br /> NAME: i th n)� ty Phone: <br /> HOME ADDRESS: I-Th 7 J-f a �. v` l Email: <br /> City r r state:6A zip: County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: F or M (circle one) <br /> Identification Type: M1Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: `7 1 Owner: t x✓ <br /> Address: diLlivvl L V. <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 b : <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: <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 to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(REHS): Date Entered: <br /> f2 <br />