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ECEIVE0San Joaquin County 1868 East Hazelton Avenue Stockton,CA 95205 Environmental Health Department Tel: (209)46B-3420 tea ✓ OCT 17 Z 0 1 Z Fax: (209)464-0138 �M.EEB��OHHDAAYNNATTGGRT FACILITY AND PRACTITIONER REGISTRATION/ ENVIRONrViEINiALFiEALTNIAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCED RES TO BE PERFORMED:Check all that apply(see back for definitions) Tattooing MBody Piercing r7mechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. 1F7'jAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification 2QAnnual Body Art Facility Permit III.APPLICANT INFORMATION: (00-7— ZI I(p NAME: Phone: - `t 3 (o g HOME ADDRESS": I-oi 9 F,re-,,v1G„n bgGyL - Email: CrMue,bi4(^&&W; I .C 0 M City: WLAV1-�C Cti State: C zip: 33 County: A upyl 7 BODY.,ART PRACTITIONER ONLY--'-;—. Date of Birth: — — 15 _] Gender: I—F-1 or (circle one) Identification Type: MDrivers License MOther Identification No.: Facility where Body Art Services Will be Provided Facili Name: i On RAd N -kr-TtDo Owner: Vio t' ✓ Address: �1 'h^ . S ✓LG+ C- CA Evidence of Six-months of Related Experience I/ FacilityName: Ih N8 owner: Z?,111 trr Address: If OL74itT -e Service You Provided: C Supervisor Name and Contact Information: C122 le ECS C3A 11 Bloodborne Pathogen Training: Submit Certificate Date Completed: I q— Zv Z Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation 1miCertification of Completed Vaccination 3MContraindicated for Medical Reasons 2MLaboratory Evidence of Immunity 4[::]Vaccination Declination IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) 1. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/Contact: Phone/Fax: 2. BUSINESS NAME: 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 tha he bes f my knowledge and belief the statements made herein are true and correct. Signature: Date: o("+ Print Name: v,,-.C, Title: FOR OFFICE USE ONLY; Program (PE) ;.. r, Fees 4.. Authorized by(RENS) Date Entered: