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San Joaquin County 1868 East Hazelton Avenue <br /> 10* Environmental Health Department Stockton, CA 95205 <br /> Tel : (209) 468-3420 <br /> Fax: (209) 464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION / <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED : Check all that apply (see back for definitions) <br /> Tattooing ElBody Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding OPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br /> IpgAnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> ?�� Annual Rnriy Art Facility Permit <br /> III. APPLICANT INFORMATION: ( /� � �7 � / <br /> NAME: ��� � �SJ11.n r Phone :f6V2t))) 2A JI`T" I I, <br /> HOME ADDREvS,�Sn U�U I, tow I +�/� Email : I UAAln ,7.i 15 COfflix� I t(I{ll <br /> city: L-I V.Q�tt t i tale : e(�, ZiUr �`i"J✓LJ County: [ a4WLdt„(/ <br /> �n7 / BODY ART PRACTITIONER ONLY <br /> Date of Birth : 1 Gender : F or M (circle one) <br /> Identification Type : 1ZDrivers License MOther Identification No . : <br /> Facility where Body Art Services Will be Provided <br /> Facilityd Name : m owner : <br /> Address : <br /> Evidence of Six- months of Related ExperienceTaboo <br /> F2ci!!r" N2^e7 Owner : <br /> Address : U S 5 (M <br /> Service You Provided : <br /> Supervisor Name and Contact Information : <br /> Bloodborne Pathogen Training : Submit Certificate _ <br /> Date Com leted : ' 5 � /� Training Provided b <br /> l S <br /> Hepatitis B Vaccination Status : Choose One and Submit Documentation <br /> 1r'lCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[Z] Laboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S) : (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: h moyflqla <br /> Location address : �1 LIL Suite : <br /> City : I t�(�, � tate : � ut, Zi-: - c Jo ui17 <br /> Owner Contact : Jan �_ � J Phone Fax : Q <br /> 2. BUSINESS NAME: <br /> Location address : Suite : <br /> City : State : Zip : County: <br /> Owner/ Contact : Phone/ Fax : <br /> The undersigned hereb a - piles for a BuQ Ari Faciiilt Fernlit and or Practitiurrer Registration and /or Mechanical <br /> g Y pp Y Y - / � g / <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 o the est of y knowledge and belief the statements made herein are true and correct. <br /> Signature : Date : y — Iq - ? I <br /> Print Name : Title : 0 (ki ` )N <br /> FOR OFFICE USE ONLY <br /> Program ( PE) : q IO Fees : ISZ Authorized by (RENS) : �� � 3 Date Entered : <br /> 1f2 <br />