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San 3oaquin CuntV 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> Fax:(209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING MOTIFICATHON <br /> L PROCEDURES TO BE PERFORMED:Check ad that apply(see back for definitions) <br /> Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br /> L—A M <br /> 0 Branding in Permanent Cosmetics <br /> 11.REQUIRED REGISTRATXWI,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> loAnnual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification <br /> 2MAnnual Body Art Facility Permit_ <br /> 111.APPLICANT INFORMATION: <br /> 5 <br /> Phone: -7 A? - q, 1 a('0 <br /> NAME: =kNE511NE- LUKE <br /> HOME ADDRESS: [ 7(2 15 Q a is&a-- Email: <br /> City: 25T &I state: CdL. Zip:2 C1 County: 51). <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: 3 Gender: F r M (circle one) <br /> Identification Type: ImDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> FacilitvName: po-%AUJO045 S&I *A Owner: 2j,PLC) 1?4jiA <br /> Address: t 7 7 0 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Sat&v% 11vt,!; owner: <br /> Address: L1 3 Lf 3 <br /> Service You Provided: <br /> Supervisor Name and Contact Information: 13 -v 4/7 <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: du fte- i`7 t),6 13 Training Provided by: /-&-,= A <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1[�UCertificatl.n of Completed Vaccination 3[=contraindicated for Medical Reasons <br /> 2[Z3Laboratory Evidence of Immunity 4[:Jvaccination Declination <br /> IV. FACILITY LOCAT ION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: QC,hWO VAL-- 5-� <br /> Location address: 07 Suite: <br /> Citv: -57-&da0-n State: /'�P- zip: County: <br /> Ownerl Contact: 0 Phone/Fax: 0 CT-3 G <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 /> TZ hereby certify that to the best of my kinowledge and belief t1he statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: eRAIE-Sr <br /> !�NE J—U kJ5 Title: &I-M a Met? Abl`s - <br /> FOR OFFICE USE ONLY <br /> Program (PE): _ Fees: Authorized by(REHS): Date Entered: <br />