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San Joaquin County 1868 East Hazelton Avenue <br /> l� a 2tStockton,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 /> ®Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> ilSaAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2aAnnual Body Art Facility Permit <br /> III.APPLICANT INFORMAATION: <br /> NAME: 1lIw( Mni -�!1* Phone:,/1q i109 12 - 1 `I OH <br /> HOME ADDR SS: aqq ��rrwl ilivc Email: -(- ( Clta>Clhn <br /> Cit State: Zip: C)S1C County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 09 Z J.2-11 1190 Gender: F or MM (circle one) <br /> Identification Type: EMDrivers License Mother Identification No.: -3 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name:iaritbolr T 1' Ownem�'hnnc V106ni <br /> Address: E • I'1 lrLb IS 2 14 <br /> Evidence of Six-months of Related Experience <br /> Facility Name:Pmc6o rhNnQ T o Vr Owner: % JInjaQ <br /> Address: 0 C (C'Jy O L] <br /> Service You Provided: e_ a <br /> r <br /> ervisor Name and Contact Informationodborne Pathogen Training:Submit Certificatea Com leted: )teaTrainin Provided b : 1 11Z%i 1�atitis B Vaccination Status: Choose One and Submit Documentation <br /> IMCertification of Completed Vaccination 3MContraindicated 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: G ,Jr <br /> � <br /> Location address: )q C L, )< I L n. Suite: <br /> Cit ; State: C ft Zi 40 County: ')rl <br /> Owner/Contact: �I'"1/AA ite lA I fl('QV Phone/Fax:( ()9 <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: _71 LI 1.2013 <br /> Print Name: Title: (ri' C) (flY-fiS <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(REHS): Date Entered: <br /> 3 <br />