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San Joaquin County 1668 Eas[ Hazelton Avenue "�:,�r Environmental Health Department stocl<con, cA 9szos .rCA,;r 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) QTattooing Body Piercing Mechanical Stud and Clasp Ear Piercing Branding ®Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1©Annual Body Art Practitioner Registration 3�Mechanical Stud and Clasp Ear Piercing Notification 2�Annual Body Art Facility Permit III. APPLICANT INFORMATION: NAME: Su`Y frt rf ivt� � BODY ART PRACTITIONER ONLY Date of Birth: � � 3 I � � � Gender: F M (circle one) Identification Type: Drivers License Other Identification No.: Facility where Body Art S��/ep/rvices Will be P//r��ovided r^ �-�,/ n,,/� Facili Name: V f--' I" pJ !'IA'1`i � C� Owner: b �uGi` ��1�r7 Address: Ivlf�N ST a1S33 Evidence of Six -months of Related Experience owner: �55)C/h q,(kv'Il%1' Facilit Name: �U�ION ON�(/�S�Ch Address: J, 23 �I1A" lfI' � `uv �pUSTI/ C"� O(S3� 1,, Service You Provided: V'OW rvi'to�Yl,pjyN" PV1 � 'Il�/t I h Ih �- rni n 1 V ✓6I -i7 Su ervisor Name and Contact Information: Sb1CA I � %I" Bloodborne Pathogen Training: Submit Certificate Date Com leted: Trainin Provided b Hepatitis B Vaccination Status: Choose One and Submit Documentation 1�Certifcation of Completed Vaccination 3�Contraindicated for Medical Reasons 2�Laboratory Evidence of Immunity 4®Vaccination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) I. BUSINESS NAME: 5`j1VTi✓ I,(�L �' �/)✓f � {" Gni Location address: I I21D. W Yn Gi.lh S'r City' YYtGv/1�1�CCA state � Zip��3� l0 �y County' dY�h ��Q'. Owner/ Contact: �`-1 L (/'t/V D�t �-� a v fi Phone/ Fax: � � J � Ui- �I 3 S 2. BUSINESS NAME: Location address: Suite: 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 t at to the bes of my knowledge and belief the statements made herein are true and correct. Signature: Date: ti %I I t ��'� Z I Print Name: _ S O1Y [^.� m', 11-e'� Title: __ � �ja'l U �'(v(/✓ FOR OFFICE USE ONLY Program (PE): �_ Fees: a) $,Q Authorized by (RENS): j(MGy Date Entered: n