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=.� o • San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Environmental Health Department <br />J 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 Body Piercing =Mechanical Stud and Clasp Ear Piercing <br />=Branding =Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 V�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: FQTSbA 1-L{Ni,3 VEV_ -' Phone: U-ixt) 2 -A% -L-133%4 <br />HOME ADDRESS: Ibco SL�A STRGE't Email:L`fAia.lLPi✓iZit�l1}RTGl7 L•7MA-LL,U1ft4 <br />City: UALT State: LA Zip: 6kS5637_ County: SA _tLA(yMVjTQ <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 17-1t tct Gender: rM or M (circle one) <br />Identification Type: Drivers License MOther Identification No.: Dq 3Sq,3>S <br />Facility where Body Art Services Will be Provided <br />Facility Name: CA,1.3V& ' K Owner: (VlcyZSSA SA T <br />Address: LA t.v PM `S-[oLK ,A <br />Evidence of Six -months of Related Experience <br />Facility Name: C Owner: M T' A TG <br />Address: 30 uA cvAtiC S-rvL, _ c a <br />Service You Provided: — <br />Supervisor Name and Contact Information: t (_204)Gt i - ttA <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: -Le %F, Training Provided by: eq <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1 r__j Certification of Completed Vaccination 3r--jcontra indicated for Medical Reasons <br />2[=Laboratory Evidence of Immunity 4E01vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: Suite: <br />City: State: Zip: County: <br />Owner/ Contact: 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 best of my knowledge and belief the statements made herein are true and correct. <br />Signature: :15:'� '2n4 Vt 14 Date: -I r 14 1 Zv ( <br />Print Name: F&MEDA U LLttvm_Title: ®LA-'We(L <br />FOR OFFICE USE ONLY <br />Program (PE): �— Fees: �SZ°" Authorized by (REHS): Date Entered: <br />