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San Joaquin County 1868 East Hazelton Avenue Environmental 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 M Body Piercing r7mechanical Stud and Clasp Ear Piercing Branding j3$ermanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES; Che[k all that apply. SEfAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification 2[:]Annual Body Art Facility Permit III. APPLICANT INFO MATION: NAME: (.O YLA. klCa''/ C Phone: 70 RQJt —I}i p( BODY ART PRACTITIONER ONLV IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) Date of Birth: 3-"20I� 9--00� Gender: F or M (circle one) Identification Type: MDrivers License MOther Identification No.: $�� Facility where Body Art Services Will be Provided Facili Name: rDLAO' S Owner: Address: �J4�2 W'A.MrY�Gtr ULK,4, 2, BUSINESS NAME: Evidence. of Six -months of Related Experience - Facility Name: Owner: Address: Location address: Service You Provided: Su ervisor Name and Contact Information: City: Bloodborne Pathogen Training: Submit Certificate Date Com leted: I �ZI`z I Training Provided by: �to Woexi Hepatitis B Vaccination Status: Choose One and Submit Documentation 1MCertification of Completed Vaccination 3MContralndicated for Medical Reasons 2[=Laboratory Evidence of Immunity 4E .Vaccination Declination t RIICTN FCC NMF• YrCh h� �X-GN�Yi. YJm t.J C Z w, thn.mn� cr 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 thate best of ty knowledge and belief the statements made herein are true and correct. Signature: Date: l0l2 I Print Name: (,OYL�iIC.IC�t'7� Y� Title: FOR OFFICE USE ONLY Program (PE): i--_ II CI Fees: Authorized by (REHS): CI !63 ( Date Entered: W10 IL 11 State: �ti ZIp: �SZt`j County Jath ,WPI Owner Contact; � v��y Phone/ Fax: Q 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 thate best of ty knowledge and belief the statements made herein are true and correct. Signature: Date: l0l2 I Print Name: (,OYL�iIC.IC�t'7� Y� Title: FOR OFFICE USE ONLY Program (PE): i--_ II CI Fees: Authorized by (REHS): CI !63 ( Date Entered: W10 IL 11