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San Joaquin County 1868 East Hazelton Avenue StoEnvironmental Health Department el: (209)kton,CA -3220 p Tel: (209)468-3420 _ v Fax: (209)464-0138 _ BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) RECEIVED Tattooing �ody Piercing Mechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics AR. 5 2012 II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. ENVIRONMENTAL H 'TM Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp EaVVRMjtIr��R n " 2r-TAnnual Body Art Facility Permit III.APPLICANT INFORMATION: I NAME: S✓ +q rl a 6d c,11 a t,, Phone�� c HOME ADDRESS: 2663 L/Y t O G k P- Email: City: C.k j+0k State: 6-P-7 Zip: County: �u n 7U es 620i'r1 r Date of Birth: 8— 2 Gender: F r MM (circle one) Identification Type: Drivers License MOther Identification No.: Facility where Body Art Services Will be Provided Facility Name: F, L )�- Z- Owner: C �t�ru fi�pl/1 Address: G,N ftrd e L rt• Ll5 Evidence of Six-months of Related Experience Facility Name: C--YC>°J L(-1u -- Owner: Address: I 40 5 , C'4e.'0 k�e e Ln • Lodi' ctj , Service You Provided: *11(4-dt lr CrC e ,- Supervisor "Su ervisor Name and Contact Information: G ff Bloodborne Pathogen Training: Submit Certificate Date Completed: 2 y Z Training Provided by: � f C Hepatitis B Vaccination Status: Choose One and Submit Documentation 1®Certification of Completed Vaccination 3MContraindicated for Medical Reasons 2[DLaboratory Evidence of Immunity 4MVaccination Declination IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) 1.BUSINESS NAME: Vd I C k t�,( L '4ty 2- Location Location address: Zv ' j« < Lrt pp Suite: City' I- v 1 State: [_1?9 Zip: ✓~2 County: 540 Owner/Contact: -5 L)I f,,ry �,ri' q 11 't In Phone/Fax: C-2-0�� .3 y� 17 T/ 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 that o the bes f y knowledge and belief the statements ma/de herein are true and correct. Signature: - Date: G -ZU'' 2- PrintName: S U 14 Ad.4 /I a 4 Title: ►'I C4ACt 9 2►r / S zc ra fia r y Oil OFfF U5Q _ , w dra �;�; � r• i�ate;E _ � _ , f2