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San Joaquin County 1868 East Hazelton Avenue <br /> Stackton, CA 95205 <br /> 7 Environmental Health Department 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 /> MTattooing8ody Piercing MMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br /> 1r7Annual Body Art Practitioner Registration 3= Mechanical Stud and Clasp Ear Piercing Notification <br /> 2= Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION :�/t <br /> NAME: `j. � ✓xt1 LN t r X0 I ' Phone: �SI 0 y 1 S �J(�^ l//✓����.,tcl <br /> p Email: S rpt �i/� I U lam" / °I✓I�' 0041 <br /> HOME ADDRESS : 33Q I lrJ e\)L �� � � fi� tC4 <br /> Cit State: CIA ZI County: 5QIA M QILI <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth : U — ( t Gender: PjVfcrrVj (circle one) <br /> Identification Type : rivers License Other Identification No. : <br /> Facility where Body Art Services Will be Provided <br /> 'Facility Name : '1- C'\ Owner: iu Cd <br /> Address : <br /> Evidence_ of Six-months of Related Experience ` ,, .{ <br /> FacilityName: - 1 'c l C� Owner: y ` 1 :(A <br /> Address : I WC7 E t&tVn G( cl C <br /> Service You Provided : Q -Ojf <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed : Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1r'lCertlfication of Completed Vaccination 3 MContra Indicated for Medical Reasons <br /> 2 [= Laboratory Evidence of Immunity 42BHaccination Declination <br /> IV. FACILITY LOCATION (S) : (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: e <br /> Location address : � �23� V�1C' iAA S T Suite: <br /> City: rj�GLI U'r" V State: C4 4 zip: c1sZOS— County: <br /> Owner/ Contact: S 1�'�l� I "'c' t t*f\ Phone/ Fax: t e�i( V) !' lz <br /> 2. BUSINESS NAME: <br /> Location address: Suite : <br /> City : State : Zip : County: <br /> Owner Contact: % / Phone/ Fax: <br /> The undersigAheTeO r BoSiy kt Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud and Ear dragrees to operate In accordance with all applicable state and local <br /> requirementsart practices or practices governing mechanical stud and clasp ear piercing . <br /> I hereby certf my knowledge and belief the statements ma a herein are true and correct. <br /> Signature : Date:Print Name : �� � �� Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE) : Fees : Authorized by (REHS) : Date Entered : <br /> fz <br />