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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health DdpartMent Stockton,CA 95205 <br /> Tel:-(209)468-3.420 <br /> • Fax:(20).-464-o138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> L PROCEDURES TO BE PERFORMED;.Check all thatapply{see,back for definitions) <br /> E3Tattooin.g 0Body Piercing [DMechanical Stud.and Clasp. Ear Piercing <br /> [DBranding Opermanent Cosmetics <br /> 11.REOUIROD REGISTRATION,PERMIT,OR NOTIFICATION FEES,Check all that apply. <br /> iEgAnnual Body Art Practitioner Registration 3[:]M.e-chahlcal Stud and Clasp Ear Piercing Notification <br /> ?E:]Annual Body Art Facility Permit <br /> 111.APPLE T INFORMATION: <br /> NAM . a Q C ,, , 2-6 CO2 Phone: Pr)q <br /> .HOME ADDRESS: c) i OXX Emailr®d�5-')&0-' (-PUM <br /> Cltv: od State, OR zip:95-4Count y,� f�.>atA ,SOCAau-k <br /> Date of Birth: Gender: Wo,MM (clircle,one) <br /> Identification Type: CglDrivers UcenseotlTer Identification No.: <br /> M <br /> Facility Where Body Art Services Will be Provided <br /> Facility Name: T%,I e- \-cA 5h Rei 9- Owner: —CA fqLkj ('mdeq <br /> Address: aca <br /> Evidence of Six-months of Related Experience <br /> Vacifty Name: Owner. <br /> Address: <br /> Service You Provided: <br /> Suggrytsor Name and Contact Information: <br /> Bloodborne Pathogen Training,Submit Certificate <br /> Date Completed., 0-9NS Training Provided by: �LO 0-C A k V\ <br /> Hepatitis B.Vaccination Status:Choose One and Submit Documentation <br /> IMCertification of Completed Vaccination 3[:3Contraindicated for Medical Reasons <br /> 2EDLaboratory Evidence of Immunity 4EgVedination Declination <br /> IV.FACILITY LOCATION(S),-(Attach additional sheets as necessary) <br /> 1.BUSINESS NAME, <br /> Location address* Suite, <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/Fax; <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 Mechanic.al <br /> Stud and Ear Piercing Notification and.agrees to operate in accordance with all applicable state and ocal <br /> requiretrients governing safe body art practices or practices governing mechanical!stud and clasp ear, piercing.. <br /> I hereby certi o nV 1powledge an lief the statements made herein are true and correct,. <br /> signatur6: .!Mto the best Date, <br /> Print Name, Title: <br /> t ON <br /> F INNR I f 5 <br /> �Zilzg-gn ?-V V <br /> M <br /> Zw 10 <br /> R M <br /> =11 Se fl, -0M.-A <br /> PTO -Utngg <br /> -'L,7 q�%bg,:(REH <br /> 3C xNil- NO, <br />