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%/y U ,A <br /> T San Joaquin County 1868 East Hazelton Ave ue 162'eSto — <br /> w 95205 <br /> *Environmental Health De artmeno el: (209)kton,46 -3420 <br /> p Tel: (209)468-3420 <br /> s:.,N 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 Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics J <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1®Annual Body Art Practitioner Registration 3[DMechanical Stud and Clasp Ear Piercing Nc;W[RIVT'4t t4S447n <br /> 2[::]Annual Body Art Facility Permit FRVICES <br /> III.APPLICANT INFORMATION: b d_ ,.q �^7 4 "7 <br /> NAME: --1—F_ - IG-PJ M 1 N/� �Z Phone:dU 1 57 /d I� ! e�y/;e �+,.,nA <br /> HOME ADDRESS: 4 F t �`�� Email: �r N KT 0000• II <br /> City: L-001 State: C14U F Zip: 9�5_;40 County: 5t4/y �� Ud4 V Ioi <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: Gender: EDor Im (circle one) <br /> Identification Type: rMDrivers License Mother Identification No.: C> <br /> Facility where Body <br /> ,Art Services Will be Provided <br /> Facility / <br /> Name: 1� ovot q Z- Owner: <br /> Address: e �C I G1 r 0 <br /> Evidence of Six-months <br /> �of"ated Experience <br /> Faci lity Name: p / 1►T Z. Owner: A <br /> Address: C, Gco�C ,��11 led OV j i C�L. 614o <br /> Service You Provided: A) <br /> Supervisor Name and Contact Information: L <br /> Bloodborne Pathog n TIHing:Submit Certificate I-' _ <br /> Date Completed: 7101 z TrainingH Provided b : � PAR ����5 ) AJ C <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1[MCertification of Completed Vaccination 3M Contra indicated for Medical Reasons <br /> 2[=ILaboratory Evidence of Immunity 4[:3Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: �� S ����L lJV Suite: rl <br /> City: Lo ( State: CA Zip: 9sa4-0 County: 6,4AJ JOQU10 <br /> Owner/Contact: 5w►y) Phone/Fax: d 09 3 39 ` <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 o the best my kno edge and belief the statements made herein are true and correct. <br /> Signature: 1`1444� Date: �uvje- <br /> Print Name: Z Title: <br /> FOR OFFICE USE ONLY �y <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> If2 <br />