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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department StocktonCA 3420 <br />p 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 Mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1bE:Annual Body Art Practitioner Registration 3F__jMechanical Stud and Clasp Ear Piercing Notification <br />2,_. _Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: y/ <br />NAME: EriGK Davrl I r✓9Gc/i2 � ,,//lynre- ' Phone: <br />HOME ADDRESS: 65-7 S gkG .NQ Ave- Email:rolerrfo&g',k- =A %r- c :;®.q w "R <br />Cit k'iC0✓1 State: G4• zip: ct 5 ?C, County: �n <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: o 13- a5 Gender: FF -1 or (circle one) <br />Identification Type: MDrivers License Other Identification No.: 63 2 C1 S <br />Facility where Body Art Services Will be Provided ,( <br />.FacilityName: 1 0 AA, <br />X1,0 �Owner: <br />Address: i 0 L -% C/kADY\ C, 5 20 <br />Evidence of Six -months of Related Experience <br />Facility Name: Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate / �/y� <br />Date Completed (, "G "2G23 TrainingProvided by: cak M�' t®1 /c, <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r__jCertification of Completed Vaccination 3F—IContraindicated for Medical Reasons <br />2=Laboratory Evidence of Immunity 4 /accination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />IF QS <br />Location address: 6 Z 6 G qGIGI hf G /qf✓t i�- {7S"Iy o C4-0 #\j _ /.' n ^I 20S Suite: <br />State: <br />Owner/ Contact: `L GS fi Z G t*1Y 5Z Phone/ Fax: <br />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 th t est of my knowledge and belief the statements made herein are true and correct. <br />Signatur Date: 0s^ 0 <br />Print Name: Gr, i' 2 4111W,f Title: <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: IS 1 <�i s, Authorized by (RENS): ,g l Vi (. Ij Date Entered: <br />