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. Sqn Joaquin County 1868 East Hazelton Avenue <br /> r Stockton,CA 95205 <br /> .Environmental Health Departmen Tel: (209)468-3420 <br /> Fdx. (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED: eck all that apply (see back for definitions) <br /> QTattooing LE]Body Piercing QMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIR REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Anrnial Body Art Drartitinnar Ranictrntinn -4rlMarhanirnl Cfiiri anri ri;tcn Far Piarrinn Nntifirnfinn <br /> 20Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: ��" ` �t��� ���1�`J Phone: <br /> HOME ADDRESS: �i Email: •i . •�41Y1 <br /> Ci State: Zip: "1 !J Coun : a l <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: ollq In( (n Gender: tMbor M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: 1 L <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 1, � p Owner: �Mr��f1 �1 \ She <br /> Add ressI \_���_ ( a ` 1i � •� 1 <br /> (Evidence of Six-months of Related Experience <br /> Facility Name::, W h ,`�, Owner:Wk <br /> Address: llrj �_ <br /> 11 <br /> Service You Provided: (� U � _ L� <br /> Su ervisor Name and Contact Information: '�-(-'Ir <br /> Bloodborne Pathogen Tra <br /> i <br /> ning: Submit Certificate <br /> Date Completed: Iv/1 Trainin Provided b :� <br /> Hepatitis B Vaccination Status: Choose One and Submit Documenta't' n <br /> I1[:3Certification of Completed Vaccination 3QContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4t•, tvaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: iN- J1 <br /> Location address: C4 CD, o-k Suite: <br /> City: �IWWState: Zi : County: \ <br /> Owner Contact: l � 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 certify that to the best of my knowledge and belief the statemMnim <br /> made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: kA QA <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> VV 1a1 I f 2 <br />