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✓ .r. • San Joaquin County S 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> Tel: (209)468-3420 <br /> x V Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> •MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION QG�'EIVED <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> ®Tattooing MBody Piercing F7mechanical Stud and Clasp Ear Piercing (!(, i 3 Q 2012 <br /> Branding oPermanent Cosmetics <br /> EWRO ENTAL HEALTF <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. PERMIT/SERVICES <br /> iJZ[Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2[::]Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> <br /> <br /> ) <br /> BODYART PRACTITIONER ONLY-:�, ; - <br /> Date of Birth: 5TP72!5t46&2_ 36 19K Gender: M or (circle one) <br /> Identification Type: EXDrivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facili n <br /> Name: 4-KO Ld4fk-' TATO Owner: <br /> Address: K!' ->-• C a <br /> Evidence of Six-months of Related Experience jj)GK <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: '� b <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 /> 1r__jCertification of Completed Vaccination 3 F-1 Contra indicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4Mvaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: ghyll!1) "ck 75+00 <br /> Location address: 15-d 5'A-tV?-AAA C'A0�V SST. Suite: c � <br /> city: Ltd State: Zi County: y1�" J��'a✓1 <br /> Owner/Contact: -5" AI&IVPhone/ Fax: ay`) 3�� - <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 tha t e best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: !V 9-0 <br /> Print Name: joie' _ Title: <br /> FOR OFFICE USE.ONLY; � =: '. _ <br /> Program (PE) Fees Authored by(RENS) Date Entered <br /> Q <br />