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San 3oaquin County • 1868 East Hazelton Avenue <br />Environmental Health Department Stockton -3220 <br />Tel: (209)) 4 4668-3420 <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 Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding aPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1[K[Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2[::]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: P ii P.N YCA-Z"E y Phone: roq 5,570 <br />HOME ADDRESS: IZ_,'O �IJUt T to C,T Email: <br />City: MKt.JTE:✓A State: LA Zip: 1?53Y 3 County: �Au Joaci� Y.� <br />Y i ! Y C s �` tr3iH <br />BOD1gft?xtAC[iThoNER.:ONLY�,x;- ,u> �_: <br />Date of Birth: O7_ -'T I -l99 Gender M or am (circle one) <br />Identification Type: MDrivers License Mother Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facilit Name: tJ ' ' Owner: N MtC *e"A,*J <br />Address: 5-Z N- C1. MfN� -VVCA 10 &A 3� <br />Evidence of Six -months of Related Experience <br />Facility Name: Owner: <br />Ad d ress: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Traininci Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2�Laboratory Evidence of Immunity 4MVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: slpr aF THE Ti, kc.LIS <br />Location address: 5 t Z 11J• v(V i CIV ( t Suite: <br />City: State: CR Zip: County: fJ iAj <br />Owner/ Contact: Au- ao" Phone/ Fax: zoq L/06 755'Z <br />I. 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 that to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: /vim— Date: <br />Print Name: 2yAst- UCAIe Title: TA1( ce � <br />