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San Joaquin County 1868 East Hazelton Avenue <br /> 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 r7mechanical Stud and Clasp Ear Piercing <br /> Branding © Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br /> 1 [7lAnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br /> 2[Z]Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: CD (A\k A 1 Y 6i 4 �\, Phone : ';40 t— (QI <br /> HOME ADDRESS : 1p-} j� i{'QI 0LC�<h \Y jA (AN" `r'r)r Email : >Oxj \t_ 21ajts�'C1' '[.( Vn <br /> Ci 1 State :, zi 67 County : <br /> (��+--t{ n, BODY ART PRACTITIONER ONLY <br /> Date of Birth : �.8 "�. AKC Gender: F or M (circle one) <br /> Identification Type: rmDrivers License MOther Identification No. : <br /> Facility where Body Art Services Will be Provided <br /> Facility Name : Owner: <br /> Address : <br /> Address : (% Ckon <br /> Evidence of Six-months of Related Experience <br /> Facility Name : v G'� Owner: 1 G1 J <br /> Address : / di tri <br /> Service You Provided : M I \ <br /> Supervisor Name and Contact Information : <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed : Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3r'lContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4[Dvaccination Declination <br /> IV. FACILITY LOCATION (S) : (Attach additional sheets as necessary) <br /> lr�1. BUSINESS NAME: G\ UIn �Q - � �Q7 <br /> U <br /> Location address : to Ulf Nc Pwe, fSuite: <br /> CI State : zip: o J () 7 County : <br /> Owner/ Contact: t-G ll'a C "JIL \n Phone/ Fax : a oQ! — (D Ael ' Zl Yl J L4 <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 to the best <br /> \o�f my knowledge and belief the statements made herein are true and correct. <br /> Signature : �t-Al Date : /W //( (,( <br /> Print Name : Title : <br /> Title : <br /> FOR OFFICE USE ONLY q <br /> '1 <br /> Program ( PE) : 110 Fees : I S2- Authorized by ( REHS) : 1 �j Date Entered : <br /> 2 <br />