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San Joaquin County 1868 East Hazelton Avenue <br />bk" Environmental Health Department Stockton, CA 95205 <br />�.'. 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 Body 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 30Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION <br />NAME: PG.n� /A Pr1 wY� Phone <br /> <br /> � <br />BODY ART PRACTITIONER ONLY <br />FACILITY LOCATION <br />Date of Birth: S CN Pj <br />Gender: F <br />or MM (circle one) <br />Identification Type: rm7 IlDrivers License MOther <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facilit Name: \ n -w 11�' <br />Owner: <br />Owner/Contac <br />Address: CfVVrV'v\ <br />Phone/ <br />Fax: <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: b) Y9 22 Training Provided b <br />own _S <br />Hepatitis B Vaccination Status: Choose One and Submit <br />Documentation <br />1®Certification of Completed Vaccination <br />3MContraindicated for Medical <br />Reasons <br />2[=Laboratory Evidence of Immunity <br />4[=]Vaccination Declination <br />IV. <br />FACILITY LOCATION <br />(S): (Attach additional sheets <br />as necessary) <br />�G) \GV <br />County �C n \L7 r�y�v\ <br />City: �-r!'i�C <br />I:i1l <br />�'c VY\ <br />State -I, <br />Zip• <br />�G) \GV <br />County �C n \L7 r�y�v\ <br />Owner/Contac <br />MNLl <br />Phone/ <br />Fax: <br />t-CjY\_���r\!::2 <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: 1?0��Ae�, ofm Date: 1� / ?jt� 2:L- <br />Print <br />ZPrint Name: -C Cl`.:��. o\ I Title: <br />1 <br />FOR OFFICE USE ONLY I' <br />Program (PE): w11 <br />0 Fees; SSL Authorized by (REHS): Date Entered: 3/3��Z Z• <br />