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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205 <br />Tel (209) 468-3420 <br />�71 *611P 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 />EjTattooing Body Piercing [:]Mechanical Stud and Clasp Ear Piercing <br />OBranding EDPermanent Cosmetics <br />11. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />07IAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />20Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION* <br />NAME- tL El ki L h� �A 6 5 Lv 1 Phone: (q`6) ? 2— <br />HOME ADDRESS: AFT. _L5? Email: _N1 _3VAC\\&6Cq c <br />City: SO -IG State: CIN Zip: ci5� I'l County: � <br />" " a 16Y , -, AkT' P lRK& kk"ONLY" <br />0 <br />Date of Birth: O 0 Gender: one) <br />Identification Type: Drivers License— [::]Other Identification No.: 172.( , —020ck6 <br />Facility where Body Art Services Will be Provided <br />Facili!y Name: I XJ 2=S\e- Owner: C5,,v\&A <br />Address:, ?.3:33 poc:%it Lv—e-. <br />Evidence of Six -months of Related Experience <br />FaciliName: Owner: <br />Address: <br />Service You Provided: <br />Su2ervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Com pleted: Train!mProvided b : t4\'0'r\3(\e <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1E3Certlflcatlon of Completed Vaccination 3[Z]C ntraindicated for Medical Reasons <br />2[Z]Laboratory Evidence of Immunity 4t�fVaccinatlon Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />I.RiPUNIESSNAMIF! IN S SV\W <br />Location address: I'l ; 9 PoC__\GC NVe - Suite: <br />gy: si-ockton State: C N Zi.: ok5ZOL4 County: Suer L\aA!a0ir\ <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 t_be best of my knowledge and belief the statements made herein are true and correct. <br />Signature: A"� fA-- /-- Date: <br />Print Name: NRTfFAN &LSAVA <br />Iff Title: <br />