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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA 95205 <br /> 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 /> ®Tattooing MBody Piercing MMechanical Stud and Clasp Ear Piercing <br /> Branding <br /> <br /> Registration 3011echanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: e- c{Qrn fwatPhone: v2-,0 qQ <br /> I .8C ,S7 <br /> HOME ADDRESS ISSW S ( AJte ^— q�y Email 1 44 aj <br /> ` e!O � <br /> Cit : state : ' zi : � 3U count : San 50049t.4r) � <br /> �1 BODY ART PRACTITIONER ONLY <br /> Date of Birth : J <br /> I3 - Gender: F or M (circle one) <br /> Identification Type : 17TDrivers License MOther Identification No. : qS <br /> Facility where BodyArtServices Will be Provided LJctY✓1 .SCQ,�e <br /> Facilityr.,.7 <br /> Name: 22 01YA � Laka Owner: 4jQ a <br /> Address : Vockhoel CA 9s- 249 <br /> Evidence of Six-months of Related Experience <br /> Faclll Name : Owner: <br /> Address : <br /> Service You Provided : <br /> Supervisor Name and Contact Information : <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed : Training Provided b <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1r7Certlfication of Completed Vaccination 3[DContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4MVaccination Declination <br /> IV. FACILITY LOCATION (S) : (Attach additional sheets as necessary) <br /> 1 . BUSINESS NAME: <br /> Location address : Suite: <br /> City: State : Zip: County: <br /> Owner/ Contact : Phone/ Fax: <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 t-o,the <br /> nbest of my knowledge and belief the statements made herein are true and correct. <br /> Signature ; fir. 11 _ ti Date: -- <br /> Print Name: �A OA QM Q,'t'�t Title : <br /> FOR OFFICE USE ONLY <br /> Program (PE) : 44110 Fees : ( $ .7 Authorized by (RENS ) ; 61 NCjf{ Date Entered : <br /> f2 <br />