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g"° San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health De artment Stockton,CA 95205 <br /> P Tel: (209)468-3420 <br /> M- Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION RECEIVED <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) I UN 0 A�t 2012 <br /> .Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding QPermanent Cosmetics ENVIRONM NTALHEAL-TH <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. RMIT/SERVICES <br /> 1 annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[n/Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: J <br /> NAME: LA0 N b016A Phone: 1 ZD.-) ) "2465 — Lf <br /> HOME ADDRESS: �J?Z_1/ C/-f/1� C 1 t Email: Al U o y6N T-1,AlLSnQ7S-(,j)OP <br /> 9(L (yi <br /> City: = ON State: C zip. Z%Z County: 41 <br /> 7w T <br /> Date of Birth: 17, Gender: M or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: 4 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: HAU LUCL L8MO Owner: F2A(� <br /> Address: <br /> Evidence of Six-months of Related Experience <br /> t� <br /> Facility Name: s Owner: < <br /> Address: _ <br /> Service You Provided: 0 <br /> Supervisor Name and Contact Information: O 06Z-001 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Trainin Provided b : DOT 16 <br /> CA <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> i <br /> 1©Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 4MVaccination Declination <br /> 16 <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME ",A r j) LU �_ TA-FmO <br /> Location address: 7 V- SAC IZAM W TO S/ <br /> City: L01)I State: KA zip: county: 5A IV ,)OAQ11I <br /> Owner/Contact: / („G� .3 -ZG�� Phone/Fax: (00 4 zD0I <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 that to the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: '004` ice, Date: <br /> Print Name: j�2 0 /�/� /y Title: A f fDO2 / t7 ttl N l� <br /> �OOFFp �w s 2 <br /> CE USG C]NL 'h:' xa, .z... �.,ta �£` �5 p, it <br /> (�iog > rF2� e ed 13�r HS atEnt�Ied�"A <br /> a rp <br /> 1f2 <br />