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• <br /> Sara 3oaquiri Countij 1868 Ea=t Hazelton Avenue <br /> Stockton,CA 95205 <br /> -� Envireni`nent l Health Depar traerit Tel: (209)468-3420 <br /> rax: (209)464-0138 <br /> BODY ART FACILITY AND PRAC T MOMER REGIST A T HOM/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFWAT-90H <br /> I,.PROCEDURESTO BE PERFORMED:Check all that apply(see back for definitions) <br /> 021 I attooing —Body Piercing Mechanical Scud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.CaE�L➢I D REGIS T G ATKOM,PEWIXT,OR NOTA FLOE o.YOM FEES:Check all that apply. <br /> Annual Body Ari:Practitioner Registration 3 Mechanical Scud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT XNFORNATION: {� <br /> lE9A��E: !` ff i Phone: I'�C1v <br /> HOME ADDRESS: Email: e ICA0, a e 0,cow <br /> City: 1 h LG! V <br /> BODY ART PRACSI° IGNER ONLY <br /> Date of Birth: -CIC) Gender: F on 4 (circle one) <br /> Identification Type: y Drivers License her Identirication No.: Co ® 1 , 3 <br /> Facility where Bondy Art Services�qpll lie Provided <br /> Facility Name: Owner: ,Q�eY)f <br /> Address: ' qS 1 <br /> Evidence of Six-months of Delated C.cPerle-rnce <br /> Facility Name: Owner: <br /> (&Lk <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact information: <br /> Bloodborne Pathogen Training:Submit Certificate <br /> Date Completed: L/ A; 2-014-1 Training Provided by: ' t o 1 <br /> Hepatitis Vaccination Status:Choose One and Sub-resit Documentation <br /> 1 E L71certificatlon of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2 Laboratory Evidence of Immunity 4 Vaccination Declination <br /> W.FACILITY LOCAiXOM (5):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: V\ kA <br /> Location address: 6Suite: <br /> Ci : 5Ljf <br /> i' State: Zip: <br /> Covu�nt : Ui j1 <br /> Owner/Contact: pi,tli A Phone/Fax: ( ®g1 "I 3 L-• <br /> 2.BUSINESS MAME: <br /> Location address: Suite: <br /> Ci'�y• 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 herclay certify hat to tft� st of rEdy lrnevurledge and G•elief the sta'terruanes made harefn. are true and correct:, <br /> Signature: ^ Date: f <br /> Print Name: j ►J��` _1 Title: ��+i <br /> FOR OFFICE USE GHL`f --------- ------- <br /> Program (PE): Fees: Authorized by(REHS): Date Entered: if 2 <br />