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r San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> rEnvironmental 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. PROCED ES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding QPermanent Cosmetics <br /> II.REQUI REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i ZAnnual 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: 13i2YAi�I I.f��u$ Phone: ("'2-Cc) <br /> <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: b 1_Q 1 Gender: F or (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facili Name: Black o.TC Z`G G PC,1 ov' Owner: Z- <br /> Address: U% i(Vr 14V . syoC'KNcl 02- <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 01.1 (7-2 1115 Training Provided by: Pv)(.)vC_TfWCUm Loam <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertitication of Completed Vaccination 3Montraindicated for Medical Reasons <br /> 2QLaboratory Evidence of Immunity 4 Vaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Rkckf(c V-C,.:5r_ TU'",X, P uk )r nn <br /> Location address: Z } - iVACir N\P-- Suite: N q <br /> City: si�cK State: CA Zip__ (15Z l�Z County: 1� !+ � 2��5 <br /> Owner/Contact: j`co0r%U UQ:iQ Q Z Lz Phone/Fax: "ZQ)q - LA5 1 - LA L- ""■■'I^UNMENT HEALTH <br /> 2.BUSINESS NAME: PERMIT/SERVICES <br /> Location address: Suite: - <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/Fax: <br /> ., tt <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 loca ONWri <br /> requirements governing safe body art practices or practices governing mechanical stud and clasp ear pi ,. <br /> � pMITJSEHi�` v�.a <br /> I hereby certify that best of my knowledge and belief the statements made herein are true and corr <br /> Signature: ��j ' `~ . Date: obi -2,3/15 <br /> Print Name: �j'tt.�Qyl CL1ffS Title: <br /> FOR OFFICE USE ONLY <br /> Program(PE): Fees: Authorized by(REHS): Date Entered: <br /> If2 <br />