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0 011V)er San Joaquin County 1868 East Hazelton Avenue Department Stockton) 46 93220 Environmental Health De p Tel: (229) 468-3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATIONLj 6.I V E� I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) a U N 2 9 2012 Tattooing MBody Piercing Mmechanical Stud and Clasp Ear Piercing IDBranding OPermanent Cosmetics WARONMENTALHEALT14 Rte..._ ..^ ` II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1E;2Qnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification 2MAnnual Body Art Facility Permit III. APPLICANT INFORMAiTnION: NAME: �554 lit 1 t? Phone: (- . BODY ART. PRACTITIONER ONLY Date of Birth: Gender: F or M (circle one) Identification Type: Drivers License MOther Identification No.: City: Facility where Body Art Services Will be Provided FacilityName: ` CIC+ tf0U jQCjV2 (()VZ -Owner: �5� U �c' I ifitb4l Address: 2 t Kk L N r iz 5.j- - Glu ii"&X Phone/ Fax: 2C`1 Evidence of Six -months of Related Experience Akti Facili Name: U&A t ' ctA Owner: iwl i5vJuZ i(I C (I'LI Address: z� tjav, S•+ Service You Provided: Gei + o a CL vL V Supervisor Name and Contact Information: 5 k Ok H U d "JOA — 2®G1• City: Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided by: County: Hepatitis B Vaccination Status: Choose One and Submit Documentation ir--ICertification of Completed Vaccination 3 MContra indicated for Medical Reasons 2F]Laboratory Evidence of Immunity 4[Dvaccination Declination Phone/ Fax: IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 1 BUSINESSNAME- jttUte C-,G�t( Tb(� Location address: e 5 jJ • itt,1eAk A Suite: City: State: C�} Zip: �9�2c�'Z County: ..Y Owner/Contact: Glu ii"&X Phone/ Fax: 2C`1 2 BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to he st of my knowledge and belief the statements made herein rare, true and correct. Signature: Date: t% Pct 'L0 " ' ( Z. Print Na Title: a L. f , °: f FOR OFFICE USE ONLY, j�� j Program (PE): Fees: Authorized by (REHS): Date Entered: {