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San 7oaquin County 1869 East Hazelton Avenue f Environmental Health Department Stockton, 46 -3220 781:(229) 463420 Fax: (209) 4644--0338 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 Mechanical Stud and Clasp Ear Piercing Branding MPermanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1ax Annual Body Art Practitioner Registration 3[:3Mechanlcal Stud and Clasp Ear Piercing Notification 2®Annual Body Art Facility Permit III. APPLICANT INFORMATION: NAME: AMYACAYA Phone: 209-815-7342 80DY ART PRACTITIONER ONLY IV. FACILITY LOCATION (S): (Attach additional sheets as necessary Date of Birth: 06/18/1982 Gender: 10 or MM (circle one) Identification Type: X Drivers License MOther Identification No.: Facility where Body Art Services Will be Provided Facility Name: EXHALE SALON Owner: ROSIE LEYVA Address: 103 W PINE STREET LODI CA 95242 City: Evidence of Six -months of Related Experience Facility Name: PRECISION BROWS Owner: JESSICA DAVILA Address: 1231 8TH STREET #400 MODESTO CA 95354 Service You Provided: PERMANENT MAKE-UP Supervisor Name and Contact Information: JESSICA DAVILA 916-698-6569 Bloodborne Pathogen Training: Submit Certificate Date Completed: 01/21/2022 Trainino Provided by: ABOVE TRAINING Hepatitis B Vaccination Status: Choose One and Submit 1 MCertification of Completed Vaccination 2MLaboratory Evidence of Immunity Documentation 3MContraindlcated for Medical Reasons 4[]3vaccination Declination ) 1. BUSINESS NAME: EXHALE SALON Location address: 103 W PINE STREET Suite: City: LODI State: CA Zip: 95242 County: SAN JOAQUIN Owner/ Contact: ROSIE Phone/ Fax: 209-430-7018. Location address: iFOR OFFICE USE ONLY d '.program (PE): _1-I I I U Fees: Suite: City: State: Zlo: 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 certifythat t t best f my knowledge and belief the statements made herein are true and correct. Signature:— Date: 01/21/2022 Print Name: AMY M ACAYA Title: PERMANENT MAKE UP ARTIST f I Sn7 Authorized by (REHS): 31 t.iF iT Date Entered: R2v121