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" San Joaquin County 1868 East Hazelton Avenue <br /> A 95205 <br /> Environmental Health Department Stockton,)(209))4468--34203420 <br /> ' 6 <br /> "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 <br /> II. REQUI ED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME Phone: S <br /> HOME ADDRESS: '" Email: ekA' g� <br /> City: `-0 ® State: C_A Zip: '? County: C'C4- U I <br /> Date of Birth: L4' - Gender: M o M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: (® <br /> Facility where Body Art Services Will be Provided <br /> e <br /> Facility Name: Owner: <br /> Address' 0LeAjajQ <br /> Evidence of Six-months of Related Experience <br /> facility Name: G (,'A� Owner: <br /> Address: So B mo <br /> Service You Provided: cvpce <br /> Supervisor Name and Contact Information: C � ®� <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3[::]Contra indicated for Medical Reasons <br /> 2[Z]Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME: r,0 a Cl Cj <br /> Location address: Suite: <br /> City: Lok State: Lk Zi Coun 0 CCs. 1 <br /> Owner Contact: L ' Phone Fax: <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 that to the be f my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: l _ <br /> Print Name: vLrIT L"L Title: 'Ta ao ' ".111 A&Vc <br /> PrO� �aE�s � �� �u3a',a 2@S� � 7 O�,�eC��l?���� $ ��€ e . Da������BI•e��' �� k� �. <br /> f <br />