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San Joaquin County �� 1868 East Hazelton Avenue <br /> a Department Stockton)CA -3220 <br /> Environmental Health De <br /> p Tel: (209)468-3420 <br /> �.., Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) IV E <br /> Tattooing IDBody Piercing Mmechanical Stud and Clasp Ear Piercing 'IN 20 2012 <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. ENVIRONMENTAL HEALTH <br /> i�Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing NdtffPKjWERVICES <br /> 2JOAnnual Body Art Facility Permit <br /> III.APPLICANT <br /> `oN INFORMATION: n./� <br /> NAME: J' )A i bw T � C2 Phone: "Ul /,� �� ✓ c7�� <br /> HOME ADDRESS: r7 pt' Email: I f� '-(��LI <br /> City: L.\\I%(2,1'' ayi� / State: CA, Zip: �'�fJ County: fiLAMEDA <br /> Date of Birth: 0 L4 Ot&Oil Gender: M or fAll ircle one) <br /> Identification Type: F21privers License MOther Identification No.: C N <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: \,L tlt7r t�I:r?J'Z Owner: <br /> Address: at I v'. <br /> Evidence of Six-mthe of Related Experience 1 <br /> FacilityName: T �,/ Owner: <br /> Address: � v GC <br /> Service You Provided: E 1 L <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> \1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> Z' Laboratory Evidence of Immunity 4[::]Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: 0 <br /> Location address: Suite: <br /> `� LVC � x��/�V E Suite: <br /> City: TC7„� f��ij State: iZ Zip: G1�D 3; 76 County: -D+* <br /> Owner/Contact: ` �, i4n.44UA-121 / 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 rning sa clart ractices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby er ' the est y owledge and belief the statements made herein are true and correct. <br /> Signature: Date: L <br /> Print Name. Title:r <br /> a <br /> ' U Q <br /> a = <br /> y. <br /> f <br /> Q, f 2 <br /> T 11���� ii. 1 <br />