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u. San Joaquin County 1868 East Hazelton Avenue Stockton,CA 95205 Environmental Health Department Tel: (209)468-3420 Fax: (209)464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEWy RES TO BE PERFORMED:Check all that apply (see back for definitions) Tattooing F7Body Piercing 71Mechanical Stud and Clasp Ear Piercing Branding 0Permanent 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[]2rAnnual Body Art Facility Permit III. APPLICANT INFORMATION: \\ NAME: L/`t�`�� dji � y_V1.V\ %AQ r'.tVC-1V 'r-ajru Phone: HOME ADDRESS: Email: }iUVh"cam,\ Y) I,r C l( z,Pn �Mct \, CU✓" �_ City: r0 C.k !� State: V� zip: C4'9- ?o J County: Su lJ1`� BODY ART PRACTITIONER ONLY Date of Birth: bi z `z q Gender: FF-1 or (circle one) Identification Type: rivers License MOther Identification No.: Facility where Body Art Services Will be Provided Facility Name: WOa h• L c,, ct• v U Owner: -vV — C,,( Address: 360 (,� a Von C rI CIS-201 Evidence of Six-months of Related Experience /^� i, Facilit Name: C/11� Owner: (� r 0 Lkv'( ' Address: G..' "I c, �-6 C Crb Ct r 20 Service You Provided: 6L k Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate t Date Completed: 2S '2 Training Provided b �l Hepatitis B Vaccination Status: Choose One and Submit Documentation 1=Certification of Completed Vaccination 3=Contraindicated for Medical Reasons 2=Laboratory Evidence of Immunity 4 Vaccination Declination IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) 1. BUSINESS NAME: Location address: 7 0 � c �A-i/ Suite: City: t C 6 State: C Zi : 01 20-1 Count Oi U Owner/_Contact: _`1�U aC-1 S 1 Phone/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 governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to the best of my knowledge and belief the statements made herein are true and correct. Signature: �(�✓•^1 �L�i T-- Date: l .Zy ZOZ Print Name: �Y{,r/qF�( r Wit/y�✓\��✓\ ("��r7 r Title: t,v w�-✓ FOR OFFICE USE ONLY Program (PE): ki I j(D Fees: 11 (,, b C) Authorized by(REHS): It t� Date Entered: If2 l