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f / <br />" • San Joaquin County• 1868 East Hazelton Avenue <br />4 Environmental Health Department CA -3220 <br />Teei:l: ( (209) 209) 468-3420 <br />°4r;zvaa,> 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 MBody Piercing r7mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 Annual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: ii y (+ <br />NAME: —TCWOV to C41 Q'\'\ Phone: <br />R <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: <br />Gender: F or` (circle one) <br />Identification Type: 1524privers License MOther <br />Identification No.: <br />Facility where Body Art Service ill b Provided <br />Owner/ Contact: <br />Facili /t <br />Name: W \ <br />Owner: e lel V QJj <br />Address: 'D <br />Evidence of Six- onths of R lated Experience <br />Location address: <br />Facility Name: +� Glh D <br />Owner: U (tiWC <br />Address: G cove- T kGT � <br />— ' K— - <br />Service You Provided: <br />Owner/ Contact: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Com leted: ' a 1 Training Provided by: U VA <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />101Certification of Completed Vaccination <br />3MContraindicated for Medical Reasons <br />2[Z]Laboratory Evidence of Immunity <br />4[DVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: <br />State: Zip: <br />County: <br />Owner/ Contact: <br />Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: <br />State: Zip: <br />County: <br />Owner/ 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 governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify th(to the be of y knowledge and belief the statements made herein are true and correct. <br />Signature: f Date: "f / 5e 1/J/ (fit/- 17 <br />Print Name: Title: T <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (REHS): Date Entered: <br />