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San Joaquin County 1868 East Hazelton Avenue Stockton, CA Environmental Health Department Tel (209) 468-34020 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) Tattooing r5ZIBody Piercing F7mechanical 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: 1p clop►" b lU iA-LLONnhg®® Phone: (,77,S") 7 $1=/ • 00 -2,1 ►�' _ BODY ART PRACTITIONER ONLY Date of Birth: ® Zdo / Gender: F or, M (circle one) Identification Type: Drivers License MOther Identification No.: Facility where Body Art Services Will be Provided Facility Name: IfV woM Tib -Mo Q►6Q-CA W 4CI Owner: OtMPr IT_ QfANKIWO Address: JCJ ' SCA 'ice !3 "r9_P-C_ L.A. (p Evidence of Six -months of Related Experience Facility Name: S Mr/1 lNk. Owner: DANE ScIA S Address: 7 -lo -9 S1 -/b fi" CA, "t 44 S-4-+ Service You Provided: 18OVY v l e 2x_l N L Supervisor Name and Contact Information: (VO 77(, • 44(052 - Bloodborne Pathogen Training: Submit Certificate Date Completed: 2-S Training Provided by: P!BO\IC TV -46O 013 Hepatitis B Vaccination Status: Choose One and Submit Documentation 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons 2[=Laboratory Evidence of Immunity 4[Mvaccination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 1 BUSINESS NAME: ikj BLC 0Pk TPrITdd + IPfE2t0N Location address: 1�) 5T2.E45T_ Suite: /3 City: 1lLk` -!4 State: CP Zip: R GQ7(P County: 9 P�N J_4061UUAJ Owner/ Contact: Ak-Dy Ps Phone/ Fax: (2-OC(1 Co 1 % - �' 1 2. BUSINESS NAME: Location address: Suite: City: State • Zip: 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 certify t ' at to the 4e�t of my kno edW6 and belief the statements mad herein are true and correct. Signature: -�- Date: a 3 Print Name: 7 'PXCAt LEV b i L .,0A.2.r¢2dZt) Title: FOR OFFICE USE ON Y / / Program (PE): J I C'" Fees: I Authorized by (RENS): G/ _� 1 Date Entered: