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San 3oaquin Cowrftii 1868 East Hazelton <br /> n Avenue <br /> Stockton,CA 95205 <br /> Envivern-rientall Heaftil DepaetnkienTel: (209)463-3420 <br /> Fa),: (209)464-0138 <br /> BODY AR-T FACM17Y AND PRACTITIONER REGISTRATI HON/ <br /> MECHANICAL STUD AND CLASP E11P.PIERCHM-3 HOTIFICATH-GH <br /> I.RPOCr--DURr--S TO BE PERFORMED:Check all that apply(see back for definitions) <br /> �attooing Body Piercing ®Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> 1L REQUIRED REGISTRATION,PERMIT,OR NOT IFY-CATIOM FEES:Check all that apply. <br /> 1FZAAnnual Body Art Practitioner Registration A�'0-1Mechanical Stud and Clasp Ear Piercing Notification <br /> 2MAnnual Body Art Facility Permit <br /> 7-11.APPLICANT XWORNATIOM: <br /> NAME:ViALe1\+ Vhl -" Phone: W—q) 'goo <br /> HOME AD[ j&hl-CF,7 :flp - Email: lilp hilbefiscau L@ jArA!af1,C0J-P, <br /> City: M32;wn State: C& Zip: 5106 County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 0!i:�Awbq Gender: F or (circle one) <br /> Identification Type: Drivers License Mother identification No.: <br /> Facility villiere Body Art Services Will be Providedl nn <br /> Facility Name: W"Jig s;l4e +e::%, *t2Ch;zj Owner: hACOA <br /> Address: <br /> Evidence of Six-months of Related Etperi[ence <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact information: <br /> Bloodbarne Pathogen Train! .Submit:Certificate <br /> Date Completed: 054/ Training Provided by: ten <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCefffication of Completed Vaccination 3Mcontraindicated for Medical Reasons <br /> 2[=Laboratory Evidence of Immunity 4=- Vaccination Declination <br /> 4® <br /> Vaccination <br /> FACILITY LOCA 10M (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: W Fnoftg Gj4e 09E]tjae *QC k4 <br /> Location address: A- 17- W- Q llaA I?MA Suite: <br /> City: &Aane-LA State: zip: County: �Ah QST <br /> Oviner/Contact: Aar 6h 'PtodrAnaaj, 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 /> S Maqp lIeVe:qEn Mve truce and Cervec:�. <br /> K Nereby ceil'ffy qla C-SE of rt-ky and L'atief statements <br /> Date: <br /> Print Nlame: Tide: AlLj: F rkrA tiov) <br /> FOR GIFFICE USE WKY <br /> Program (PE): L+ Fees: Authorized by(RENS): _Date Entered: <br /> if�i <br />