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=p San Joaquin County 1868 East Hazelton %%enue <br /> Environmental Health Department Stockton, CP 305205Tel: (209)468-3420 <br /> Fax: (209)4&"138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCED RES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> attQoir g MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> 03randing Opermanent Cosmetics <br /> II. FtEQU D REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> v nnual Body in Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notificatim <br /> :.[ - nual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: V.a,(,( eA o Cy\o\\\- L) I,^ eA Phone: 0-0�) 33� — C� 83-7 <br /> HOMEADORFSS: ?yc'�1 McAv- ;Vne Pr\iQ Email: .ZI67AV-MCA✓'Ce-kj0 <br /> -T <br /> City: State: /'f zip: S�2 `` CountfAtn <br /> )c <br /> BODY'ART PRACTITIONER ONLY <br /> Date cf 6 rth: 0'7 ` qLA e Gender: F M (circle one) <br /> Idertifice:ion Type: mDrivers License Other Identification No.: <br /> Fac lity where BoJy Art Services Will be Provided <br /> Faci ity Nam=: �0 C— Utfi C Owner: i YY <br /> Add-ess: t1 VW u./ <br /> Evide,tce of Six-months of Related Experience <br /> Faci it- Nam=_: I h+fi .: n Owner: Pc�tM�(✓1 G�Ulee!e <br /> Add-ess: a ` ' �V' u- <br /> Service Y)u orovided: 0 0 <br /> Su =-rvcs_r Name and ::cntact Information: <br /> B ooctcrne Pathogen Training: Submit Certificate <br /> Date Cor feted: Z,J I Z4 Training Provided by: <br /> HiWatitis B Vaccination Status: Choose One and Submit Documentation <br /> :r--J---=rtifcaticn o=,--ompleted Vaccination 3r--j Contra indicated for Medical Reasons <br /> ::[:3Laboratory Ev thence of Immunity 4 accination Declination <br /> IV. FACILITY LCCAT104 (S):(Attach additional sheets as necessary) <br /> I. 3USZMESS NAME: <br /> Locetion adcress: Suite: <br /> Ckv: State: Zip: County: <br /> Omer/CGntact: Phone/ Fax: <br /> 2. 3USiMESS NAME: <br /> LocEtioi adcress: Suite: <br /> City: State: Zip: County: <br /> O_vw erl Contact: Phone/ Fax: <br /> The .rde-s geed hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud .and Ear Piercing No:ification 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 certi=y that trjE be of my knowledge and belief the statements made Perein�are <br /> �true and correct. <br /> �Signature: Date: ID.I �''f-1 <br /> Print flame: CA ovcti� Title: j�jAc'+) b pyyy <br /> FOR DFFICE USE ONLY <br /> ProgrEm ;Pq: Fees: Authorized by(REHS): Date Entered: <br /> if 2 <br />