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EnVlronmen1a1 'leann Departme Tel: (209)468-3420 Fax: (209)464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. l - Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification 2[H]Annual Body Art Facility Permit III.APPLICANT INFORMATION: '% NAME: r"4% krfa- .n Phone: �bQ+CJS 37.`13 f HOME ADDRESS: �-�J� WLh�rL�64► W a Email: kt`e �r101W`6\6 .COM city: LCX�1 State: C-A- Zip' ck6I%AIL County: gor1 �pp.C�U,LNy Date of Birth: Awj- Gender: F or M (circle one) Identification Type: EDrivers License Other Identification No.: Facility where Body Art Services Will be Provided � FacilityName: ^`a-Wy , `S®4Owner: \\a`1 Qk1 `Y1 Address: `eou W 1,.Dc�.� �VQ� �•Da`t , ��il\k� Evidence of Six-months of Related Experience Facility Name: Owner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Completed: "ho I \la Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation 1®Certification of Completed Vaccination 3 Contraindicated for Medical Reasons 2 Laboratory Evidence of Immunity 4 Vaccination Declination IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) 1. BUSINESS NAME: Location address: Jj®(3 ��`-'` �^-�d 0 NVQ. Suite: City: �-EX�e State: °�A• Zip: (AtAL1C) County: S&f\ Opo, ,ti Owner/Contact: Q`� `JQQe`n 2\r\ Phone/ Fax: a041• lb!6u•,Sal%' 2. BUSINESS NAME: V Location address: Suite: City: State: Zip: County: Owner/Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify th9tAo the best of my knowledge and belief the statements made herein are true and correct. Signature: Date: 14'4 Print Name: CPQ` ' eQ .ns4e l rl Title: