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Mechanical Stud and Clasp Ear Piercing <br />F (circle one) <br />Owner: <br />State: <br />State: <br />/A La <br />Fees: ±17A Authorized by (REHS): Date Entered: <br />TO 2 <br /> Suite: <br />County: <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Tel: (209) 468-3420 <br />Fax: (209) 464-0138 <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />I | Body Piercing <br />| (Permanent Cosmetics <br />■|-^|Tattoolng <br />| (Branding <br />jContraindlcated for Medical Reasons <br />^Vaccination Declination <br />________Zip: <br />Phone/ Fax: <br />________Zip: <br />Phone/ Fax: <br />_________Gender: <br />Identification No.: <br />Suite: <br />County: <br />OwnenTJo V\u VyL S <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />JV- FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: <br />City:______________ <br />Owner/ Contact: <br />2. BUSINESS NAME: <br />Location address: <br />City: <br />Owner/ Contact: <br />FOR OFFICE USE ONLY <br />Program (PE): *///Q <br />---------R5V ------------------------------------- <br />sssssssssse:"' <br />I hereby certify that to thebest of my knowledge and belief the statements made herein are true and correct <br />S'9naturc: ^2= X._____________Date: _2-LlLJ H $~ <br />P“e: aAC^Vs,. TTCerg^G <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />iQAnnual Body Art Practitioner Registration B^Mechanlcal Stud and Clasp Ear Piercing Notification <br />2| lAnnual Bodv Art Facility Permit <br />or I MDate of Birth: O <br />Identification Type: Drivers License| (other <br />Facility where Body Art Services Will be Provided <br />Facility Name: T fi-VAr 0 0 <br />Address: S\^- N VnlOh <br />Evidence of Six-months of Related Experience <br />Facility Name: <br />Address: _________ <br />Service You Provided:_____________________ <br />Supervisor Name and Contact Information:__________________ <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 2 / | ------------Training Provided by: N t h(J h <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation ' <br />1||Certification of Completed Vaccination 3 <br />2|JLaboratory Evidence of Immunity <br />III. APPLICANT INFORMATION: <br />NAMB: AciO'QO- NWfhlA _______________Pbpne: ("ZO CA\] ' A (, <br />honeaddress: ZzL email: <br />Chy: C-erCS----------------State: C A Zip: I County: fab S J <br />BODY ART PRACTITIONER ONLY