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San Joaquin County • 1868 East Hazelton Avenue <br />—.F- A 95205 <br />Environmental Health Department Stockton <br />P Tel: (209 )) 4 468--34203420 <br />• ,. -:•, 6 <br />"1 <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 />i�Annual Body Art Practitioner Registration 3©Mechanical Stud and Clasp Ear Piercing Notification <br />2[::]Annual Body Art Facility Permit <br />III. APPLICANT INFOR�TION' �r � � 4t7NAME: GLS ' � Phone: <br /> <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: :5j`—)7j'71 <br /> (circle one) <br />Identification Type: rivers License MOther <br />Identification No.: % <br />Facility where Body Aft Services Will be Pro ided <br />FacilityName: \/Q tA <br />Owner. <br />Address: 1 G <br />f�tn <br />Evidence of Six,-monty of Related Exp`e'rriien e <br />FacilityName: LA h O. /A 63 <br />Owner:t�-;CNV- VL1 aA�- <br />Address: j <br />C, o L <br />Service You Provided: I M it <br />Supervisor Name and Contact Information: C <br />Bloodborne Pathogen Trai ing: Submit Certificate <br />Date Com feted: Z�' Training Provided by: <br />Hepatitis B Vaccination St6tus: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3Mcontra indicated for Medical Reasons <br />2[=Laboratory Evidence of Immunity 4Mvaccination Declination <br />IV. FACILITY LOCATION (S): (Ah additi nal sheets nq <br />1. BUSINESS NAME: L.�i <br />Location address: E'A0- <br />Citv M -A Pt --i-4 State: <br />Suite: <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 th Abst o kno d an elief the statements made herein are true and correct. <br />17 <br />Signature: ! ' _ Date: f <br />Print Name: 3 Title: —TGt O53 <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (RENS): Date Entered: <br />•) <br />