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San Joaquin County 1868 East Hazelton Avenue 1Environmental Health Department Stockton, CA 95205 P Tel: (209) 468-3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ , MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED; Check all that apply (see back for definitions) (Tattooing =Body Piercing MMechanical Stud and Clasp Ear Piercing =Branding ®Permanent Cosmetics II. REQUI EDnRIlEGISTRATIONI PERMIT, OR NOTIFICATION FEES; Check all that apply. al Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification gAnnual Body Art Facility Permit III. APPLICANT INFORMATION: SSS Ogzs BODY ART PRACTITIONER ONLY Date of Birth: oi- L`1 - IN io Gender: F o M circle one) Identification Type: License MOLher Identification No.: MDrivers Facility where Body Art Services Will be Provided Facility Name: LucWy yat& kaAao owner: C'Iniho f.,r;a Address: iii$ Nf mitith i; Ma1A+4(V' C0. Evidence, of Six -months of Related Experience Facility Name: Owner: Address: Service You Provided: Supervise Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation 1r"ICertification of Completed Vaccination 3MContraindicated for Medical Reasons 2[=Laboratory Evidence of Immunity 4 Vaccination Declination FACILITY LOCATION (S)The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner IV. �: (,eA-ttarc�h�2additi/onal sheets as necessary) I. BUSINESS NAME: 7rY, rt ID DAG Location address: Suite: City: State: Y Zip: County' Owner/ Contact: Phone/ Fax: 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County; Owner/ Contact: Phone/ Fax: 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 of y knowledge and belief the statements made herein are true and correct. Signature: c� Date: H�9, 7 2_ / Print Name: .,. e� Cie Title: FOR OFFICE USE ONLY Program (PE): Fees Authorized by (RENS): Date Entered: 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 of y knowledge and belief the statements made herein are true and correct. Signature: c� Date: H�9, 7 2_ / Print Name: .,. e� Cie Title: FOR OFFICE USE ONLY Program (PE): Fees Authorized by (RENS): Date Entered: FOR OFFICE USE ONLY Program (PE): Fees Authorized by (RENS): Date Entered: