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1868 East Hazelton Avenue <br />San Joaquin County Stockton, CA 95205 <br />Environmental 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 />[EfTattooing ®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 />1EMAnnual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br />20Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: 1 <br />NAME: J a, ,, Y ®,n`1!� ®� `-- Phone: cjj ( 4 y (I 9 <br /> <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: & -vs' <br />Location address: ® C Suite: <br />City: L I State: CK Zip: 40 County: 54 YN <br />Owner/ Contact: ,S ®1 \ Phone/ Fax: --2-001 S-2' <br />Location address: ' v W'%-VS Suite: <br />Citv: V1 State: ck Zip: II County: Sa <br />Contact: <br />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 gov rning safe body art practices o ractices governing mechanical stud and clasp ear piercing. <br />I hereby certify to the besttf my wled nd belief the statements made herein are true and correct. <br />Signature: 4I Date: �- <br />Print Name: o 1( Title: q A.Nr O <br />2 <br />