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San Joaquin County 1868 East Hazelton Avenue <br />Stockt <br />Environmental Health Department on, <br />CA 9s2os ft420 <br />s mak,, <br />,y Q;,•* 4 <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 ®Mechanicai Stud and Clasp Ear Pierc VIRONMENI',q, HE <br />PEM17� <br />Branding ®Permanent Cosmetics S R`/If;�T� <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: I?A V ( <br />City: Alta eeot state: LA Zip: County: <br />ZOq 1470-'17H Z <br />obm <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 17-1 cl -1 f117-7 <br />Gender: [Z]or M (circle one) <br />Identification Type: =Drivers License Other <br />Identification No.: -700 <br />Facility where Body Art Services Will be Provided <br />Facili Name: V yo '}'a hr� <br />Owner: 5^r C',fJjre$ <br />Address: 'Z 0 & a+L,i {., "' S <br />C'�KA-0^ CA <br />Evidence of Six -months of Related Experience <br />Facili Name: <br />Owner: <br />Address: <br />F tDrG5 Phone/ Fax: <br />Service You Provided: <br />2. BUSINESS NAME: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: "�© 17- Training Provided by: � ��1 M012W e5 C5o,�Af i- <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation LorhVIHN y <br />i®Certification of Completed Vaccination 3®Contraindicated for Medical Reasons <br />2F -N Laboratory Evidence of Immunity 4®Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: L) f -�o NJ y1 =T=' K k - <br />Location address: 32o <br />� <br />ea& ;4i& A.le, <br />Suite: <br />City: '54 -OL k�-" <br />State: Ctl Zip: <br />°1520, County: 6^4 <br />Owner/ Contact: Ce -'5µ <br />r <br />F tDrG5 Phone/ Fax: <br />-L-01 N lv `a- 12 v v <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 g g safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certi tat to st of my knowledge and belief the statements made herein are true and correct. <br />Signature: Date: <br />Print Name: Title: -:,e <br />FOR OFFICE USE ONLY t <br />Program (PE): Fees: Authorized by (REHS): Date Entered: l <br />f2 <br />