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San Joaquin County <br /> 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA 95205Tel : (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 /> F'jTattoolng Body Piercing Mmechanjcal Stud and Clasp Ear Piercing <br /> Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br /> 1 i/ nnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2[DAnnual Body Art Facility Permit <br /> III. APPLICANT INFORMATION : <br /> NAME: whonj Nana <br /> � � N Phone : T Zoa� ?A Z��O ✓ <br /> HOME ADDRESS : n � ISUY W K/'� DE ffin f �I � Email : ' Np C�y-yY �pN/111 �, 5 0' 5M� AlL • aM <br /> City : SIGGKTG1N State: (A Zip : ✓TA 2 County : kD N . dhaulN <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth : Gender: M or rssFM I (circle one) <br /> Identification Type: MDrivers License MOther Identification No. : <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: SAL6X: F J3tLL��� Owner: L6 �>7l� 77 <br /> Address : � �94b MC IFIL AVIAME S ToOcPA) <br /> Evidence of Six,,m� onths of Related Experience _ <br /> Facility Name : 5�1�/v Iii✓ � LL�Z�A owner: LA ly <br /> Address : hnj )P;9Lf-F1& ii vaUESj G 1-0 � <br /> Service You Provided : M )CO 8 t /TD <br /> Supervisor Name and Contact Information : /ho RP 4) <br /> Bloodborne Pathogen Training: Submit Certificate CIA 6I FD (' /U /'q /7� C l3 LCIf)1�.130 ��`I% <br /> Date Completed : VIII f 2 L TrainingProvided b /" <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> SQCertification of Completed Vaccination 3lIContraindicated for Medical Reasons <br /> 2[DLaboratory Evidence of Immunity 4[::]Vaccination Declination <br /> IV. FACILITY LOCATION (S) : (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: ,� �y D P '� � IGVE�U� l ` l Suite: <br /> City : apC Lrzi "J State : Zip : County : <br /> Owner/ Contact: Itip94'1y/j T y Phone/ Fax: 6�Z/� "I 4 31 < / <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 t the best of my knowledge and belief the statements' (made �herein are true and correct. <br /> Signature : •`��'y"�-�l� 1 l �o �� Date : <br /> Print Name: NVl �1 V\4 I / LtR4 qkA �-f' � Title : S <br /> FOR OFFICE USE ONLY <br /> Program (PE) : h•II ! 0 Fees: 4 J $ ,2 Authorized by ( REHS) : 61m & 1,1 Date Entered : <br /> 1f2 <br />