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San Joaquin County 1868 East Hazelton Avenue Stockton,CA 95205 Environmental Health Department p Tel:(209)468-3420 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) MTattooing 08ody Piercing Mmechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics II.REQUIR REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. 1 Annual Body Art Practitioner Registration 3[::]Mechanical Stud and Clasp Ear Piercing Notification 2[DAnnual Body Art Facility Permit III.APPLICANT INFORMATION: NAME Phung Le Phone: (916)873-4372 HOME ADDRESS: 8251 MedelroS Email: Phungtion@gmali.com City: Sacramento WaVttate: CA zip: 95829 County: Sacramento $ODl(•ART PRACTITIONER ONLY Date of Birth: 04/07/1997 Gender: or MM (circle one) Identification Type: InDrivers License MOther Identification No.: F5220357 Facility where Body Art Services Will be Provided Facility Name: h Owner: S- i Address: S� LYACAe Evidence of Six-months of Related nnExperience Facilit Name: V `ah ( Owner: Address: JIACitee/ S�Wn q J Service You Provided: Supervisor Name and Contact Information: #_ Bloodborne Pathogen Training:Submit Certificate Date Completed: Training Provided by: Cathy Montie Hepatitis B Vaccination Status:Choose One and Submit Documentation 1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons 2QLaboratory Evidence of Immunity 4�ccination Declination IV.FACILITY LOCATION (S):(Attach additional sheets as necessary) 1.BUSINESS NAME:�j�- - f ' Location address: ns cJ� (moi( Suite: Cit State: Zi : R CountyAln Owner]Contact: ( ) PhoneI Fax: ' 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 goveming safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to th t 9fi my knowledge and belief the statements made herein are true and correct. Signature: Date: (21/()4/20209 J Print Name: phi Inn 1'a Title: E I^4)R QFfICE USE ONLY r�gram{PE) / j iced by(REHS). Date Ente Prf ate; ' 'eS �� '�"