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---------- <br /> i,-- ---------- <br /> san 3oaquin Countil 1868 East Hazelton Avenue <br /> Sto cl(ton,CA 95205 <br /> 14, Erivirenrnental HeEdth Departrrieiit —let: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITV AND PRACT IT XOMER REGIST m ION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING MOTIFICAT AKOM <br /> Z.Pp,0CEDURESS TO BE PERFORMED:Check all that apply(see back for definitions) <br /> Mi attooingr='-7Body Piercing MMechanical Stud and Clasp Ear Piercing <br /> L-1 <br /> Branding ®Permanent Permanent Cosmetics— <br /> 11.REQUIRED REGIS TRATKOH,PERMIT,OR N@T-&F-7cA-i101,j FEES:Check all that apply. <br /> 2gnual Body Art Practitioner Registration 3F­lMechanfcal Stud and Clasp Ear Piercing Notification <br /> nual Body Art Facility Permit <br /> Hal.APPL-KCANT XNFORMATION: <br /> NAME: Phone.n n P 1Z,41 Za <br /> 5d)n '. V ��!ffae6b,- <br /> HOMEADDRESS: Email: e. <br /> Cit state: Zi i): County., <br /> BODYAATPRACTITIONER ONLY <br /> Date of Birth: q-ZO- 75? Gender: F orlm (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility viihere Body Art Services Will be Provided <br /> Facility Name:_A/Ok 12 a� 0401A A ddZkgwner: <br /> Address: r <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 /> Bloodbarne Pathogen Training:Submit Certificate <br /> Date Completed: Training Provided by: <br /> p,spatitis B Vaccination Status:Choose one and Submit Documentation <br /> 1MCertification of Completed Vaccination 3[=con-'Lraindicated for Medical Reasons <br /> 2[:31-aboratory Evidence of immunity 4[mVaccination Declination <br /> XV.FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> ) 'I A <br /> 1. BUSINESS NAM4�0 <br /> E: A %aI 11Z <br /> 1 <br /> Location address: 2,17 Suite: <br /> Cizip: <br /> State: Countv: <br /> ty: 5Z(-1c7Mbt! &A, —�� A 14 <br /> Phone/Fax: !1201P�5 .. <br /> Owner/Contact: 45611 <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 /> 7-Nereby certify that to the best dg� Gelled the statements made harain, are tvue and cub'rEct- <br /> Signature: Date: <br /> Print Nlame: 1/%, Title: <br /> 7V <br /> FOR OFFICE USE GHLY <br /> Program (PE): Fees: Authorized by(REFS): Date Entered: <br />