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' . San Joaquin County • 1868 East Hazelton Avenue <br /> Stockton,CA <br /> ' Environmental Health Department el (209)468-34020 <br /> ,.., Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I�I�i�c,l�/E® <br /> I. PROCE RES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing Body Piercing OMechanical Stud and Clasp Ear Piercing JUL 2 2012 <br /> Branding Permanent Cosmetics <br /> TAL HEALTH <br /> II. REQRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. PERMIT/SERVICES <br /> i Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICA T INFORMATION: I <br /> NAME• (O-tA 11,-_ LP (,v 'i 5 Phone: (ZVCI) <br /> GI ZZ— 3C (/8 <br /> HOME ADDRESS: q 3 9 9 4j2 I r r P_��c` Com{ Sj2C,�8 Email: Qtnot-t Gt I 138 1w CO •C6r_--' <br /> City: State: Zip: 9S--33-1 County: <br /> E hi <br /> . - <br /> Date of Birth: U 1 Gender: F or (circle one) <br /> Identification Type: Drivers License MOther Identification No.: U <br /> Facility where Body Art Services Will be Provided <br /> Facilit Name: C v" �" Cil Owner: <br /> Address: 'S 'E <br /> Evidence of Six-months of Related Experience <br /> Facility Name: �� Owner: Cc. Q <br /> Address: Z-C- cf 1M <br /> Service You Provided: k <br /> Su ervisor Name and Contact Information: VvA ZOG C 1 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 'Z/ ?_O Training Provided by: (h lC6 P, jo pool 10� <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> IMCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4121Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1 BUSINESS NAME: `r-kA., a.✓ CV D{e.&z.1V\C.k <br /> Location address: �-5—q l.✓- JOSe✓v d{"�.^d�/ e✓ Ili Suite: <br /> & <br /> City: `C`__+-;e—C-Cti State: C'4 . Zip: 9633 & county: <br /> Owner/Contact: �"Zc'4� Zy ._�+-L ZL( 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 certifyth o the best of m cno dge and belief the statements made herein are true and correct. <br /> c <br /> Signature: Date: <br /> Print Name: ` S. C-ecvlS Title: <br /> S OY <br />