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• I <br /> y San Joaquin County 1868 East Hazelton Avenue <br /> CA 95205 <br /> Environmental Health Department Stockton <br /> Tel: (209))468-3420 6 <br /> * Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATIO D <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) JUN 2 0 2012 <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing G <br /> QBranding QPermanent Cosmetics ENVIRONMENTALHEAI_TH <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. I ES <br /> it-WfAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2MAnnual Body Art Facility Permit <br /> III.APPLICAN1T INFORMATIO . <br /> NAME: �5�q/,/hF, JQ.IdS Phone: _913.3140'7355 <br /> <br /> <br /> <br /> - <br /> �, >,.B8 R!k P. OIEy v <br /> Date of Birth: 5' .c0 ' 1 Gender: pM or FIR (circle one) <br /> Identification Type: MDrivers License MOther ^ <br /> Facility where Body Art Services Will be Providedl, <br /> Facilit Name: ^ d Owner: u d' <br /> *Owd <br /> Address: <br /> 51 Aulf , <br /> Evidence of Six-months of Related Experience <br /> Facility Name: VA 14 Owner: �h <br /> Address: l( ,/ <br /> Service You Provided: 4A T400 <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: V ' Training Provided by: FMAOY-Ak 4; VA <br /> H�e�pitis B Vaccination Status: Choose One and Submit Documentation <br /> � Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2�1Laboratory Evidence of Immunity 4[::]Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets'as necessary) <br /> 1. BUSINESS NAME: Q M N%Ved +91AAU D <br /> ` Q�/� _ <br /> Location address: 911 } "a' A U f' Suite: <br /> City: ttA State: eN Zi : cs ?(O Count N lahqk h <br /> Owner/Contact: J . 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 th to the best,of my k owledge and belief the statements madehereinare true and correct. <br /> Signature: Date: lei - tg— <br /> Print Name: 111 0, 141 AdcTitle: 4A&Wv <br /> OF 5,4. <br /> a a <br /> f2 <br />