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07/13/2012 11:02 2098305045 UPS STORE 3968 PAGE 02 <br /> • San 3oaquin County � 1.868 East Hazelton Avenue <br /> Environmental Health Department Sfickton,CA 95205 <br /> Tel; (209)458-3420 <br /> Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I.PROEDURES TO RE PERFORMED:Check all that apply(see back for definitions) <br /> Tattooing QBody Piercing [MMechanlcal Stud and Clasp Ear Plercing <br /> Branding Permanent Cosmetics <br /> 1.REUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> I Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Plercing Notlflcatlon <br /> 2 Annual Body Art Facility Permit <br /> 111.APPLICANT INFORMATION: rr__u <br /> NAME., Phone: 0A �0 to <br /> HON E ADDRESS: ;5 Email: <br /> CIt3`e: zi County: <br /> Dat of Birth: J Gender: M or M circle one <br /> Iden Ificatlon Type: Drivers License Other identification No. <br /> Faei ity where Body Art Services Will be Provided <br /> Facll ty Name: Cs o Owner: <br /> Addr ass: (10 <br /> Evidence of Six-months of Related Experience <br /> Facil ty Name; r Owner: <br /> ly- <br /> Addr ass, <br /> Se cc You Provided: <br /> Su rvisor Nance and Contact Information: <br /> Bloc dborne Pathogen Tralning: Submit Certificate <br /> Dat ! <br /> Completed; 7 161 'tbi 2 Training Provided by: ('� �f 4 tq <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> Certification of Completed Vaccination 3M Contra Indicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4[MVaccination Declination <br /> FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: CSC-�_ <br /> Loca ion address: Suite: <br /> Clt State: Zi County: <br /> Owner/Contact: Phone Fax: 22211 Wlt) <br /> 2, BUSINESS NAME: <br /> Loca Ion address: Suite: <br /> City: State: zip: County: <br /> Owner/Contact: Phone Fax: <br /> The un erslgned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud a d Ear Piercing Notification and agrees to operate in accordance with all applicable state and local <br /> requirements govern) a c ice r practices governing mechanical stud and clasp ear piercing, <br /> herak y certify at to the be wle -a d belief the statements-made herein are true and correct, <br /> ignatu e: Date: / <br /> rint No Tie: Title: <br /> 12 <br /> Received Time Jul. 13. 2012 10: 58AM No. 0542 <br />