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• San Joaquin County • 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> �- <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 =Body Piercing =Mechanical Stud and Clasp Ear Piercing <br /> =Branding M Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1JL]Annual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> ( <br /> NAME: (a-0t) t/1' � � (y�ll�ifl Phone: <br /> <br /> <br /> <br /> � OARTPRACT T GIVE.' i .. � % O <br /> Date of Birth: 8 ,7Gender: or M (circle one) <br /> Identification Type: rivers License MOther Identification No.: <br /> Facility where Body <br /> /Art Services Will be Provided <br /> FacilityName:C%K/1 le, 14n1-r- e✓) T Gam- Owner: AdSi6 W" <br /> Address: 103 !✓ // �46> <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: 7 / TrainingProvided b r(� U x 1 l/Z4.S <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2C]Laboratory Evidence of Immunity 4[aVaccination Declination <br /> IV. FACILITY LOCATION (S):/r(Attahh additional sheets as ne essary) <br /> 1. BUSINESS NAME: <br /> Location address: i-)e Suite: <br /> /,A— <br /> City: Qti State: Zi : o� Count ! <br /> Owner/Contact: Phone/ Fax: 614 3 33- ".3 <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 thijto the b st knowledge and belief the statements made herein are true and correct. <br /> Signature: / � Date: _4 o?Print Name:Name: t') Title: <br /> FO ,® <br /> / • <br />