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San Joaquin County 1868 East Hazelton Avenue <br /> 1 Stockton , CA 95205 <br /> Environmental Health Department 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 Body Piercing aMechanical Stud and Clasp Ear Piercing <br /> aBranding EDPermanent Cosmetics <br /> II . REQUIR ! D REGISTRATION, PERMIT, OR NOTIFICATION FEES : Check all that apply . <br /> 1 nnual Body Art Practitioner Registration 3a Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III . APPLICANT INFO\ IRMATION : �f Iwo <br /> r <br /> NAME : CIrA YQ,QQ Phone : ���I ' Iwo 0 I9 20 <br /> HOME ADDRESS : n Me Email : 6kjCjQNjPAA W5� L . um <br /> City : State : eq Zip : 85350 County : <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth : Gender : or MM ( circle one ) <br /> Identification Type : =Drivers License Mother Identification No . : 15 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name : Owner : <br /> Address : <br /> Evidence of Six- months of Related Experience <br /> Facility Name : QPA Owner : <br /> Address : 910 9M, <br /> Service You Provided : <br /> Supervisor Name and Contact Information : Z <br /> Bloodborne Pathogen TrIraining : Submit Certificate L <br /> Date Completed : ` , TrainingProvided b T <br /> Ij 1.j <br /> Hepatitis B Vaccination Status : Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2 [= Laboratory Evidence of Immunity 4 ® Vaccination Declination <br /> SUNNI <br /> IV . FACILITY LOCATION ( S ) : ( Attach additional sheets <br /> aa"s 'necessary ) j� n <br /> 1 . BUSINESS NAME : <br /> Location address : L,3V1 �� )� Suite : <br /> Cit State : Zip : County : \ � <br /> Owner Contact : Phone Fax : 20a lob '503(o <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 gover safe body art practices or practices governing mechanical stud and clasp ear piercing , <br /> I hereby certify t at to he est of my knowledge and belief the statements made herein are true and correct. <br /> Signature : Date : O <br /> Print Name : Title : <br /> FOR OFFICE USE ONLY $ 152 + $233 = $456 � ; <br /> Program ( PE ) : 4110 , 4120 Fees : Authorized by ( RENS ) : Al tP< Date Entered : <br /> a Ve a , Authentic ma es Tattoo 211 99 ac c on Avi scalon ) 5320 . <br /> if 2 <br />