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San Joaquin County ® 1868 East Hazelton Avenue <br /> 40 <br /> Environmental Health Department Stockton,CA 95205 <br /> >' p 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 OBody Piercing Mechanical Stud and Clasp Ear Piercing <br /> ®Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1FZZlAnnual 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: ar t .-z I11 Phone: lei 3 <br /> It HOME ADDRESS: 17Z Low l/e Email: 1 r 'Z c-( Li I CIC/ c ctil <br /> City: M 0dState: L3 zip: County: SCIa ,T 66 0Aa°ft CC'�a�t� <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Z- 06- 1611d Gender: F or M (circle one) <br /> Identification Type: Drivers License C30ther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> i <br /> Facility Name: _TC( CSD Owner: <br /> Address: I /)1 V fto f <br /> Evidence of Six-months of Related Experience , <br /> ra <br /> Facility Name: isoci 5,Lit, <br /> I It Owner: <br /> Address: Z - , i, G� I/ <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> / <br /> Date Completed: Z / ( Trainin 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: _71 'Z91 12 <br /> r <br /> Print Name: Cc N( Title: "eA+fO 0 S� <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: bO Authorized by (REHS): Date Entered: <br /> If2 <br />