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r <br />f <br />y <br />San Joaquin County01 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Environmental Health Department Tel: (209) 468-3420 <br />Fax: (209) 464-0138 <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing =Body Piercing =Mechanical Stud and Clasp Ear Piercing <br />Branding =Permanent Cosmetics <br />II. REQUIRED REG%STRATION, PERMIT, OR NOTIFICATION FEES; Check all that apply. <br />1 nnual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT I FORMATIION: /� t l '1 <br />NAME: ® `/ ✓�� I Phone: a 3 117 5 3 3 } <br />MIF <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: (4-5— Gender: F or MM (circle one) <br />Identification Type: Drivers License Other Identification No.: <br />Facility where Body Art Services Will be Provided tt <br />FacilityName: Until^ CL{ O J Pt'-krLcq Owner: O s �(� e <br />Address: I N UlI <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 />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1 Certification of Completed Vaccination 3 [::]contra indicated for Medical Reasons <br />2 Laboratory Evidence of Immunity 4 accination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: L/,\"(g,\ -�-[+-0 ® ; e -C G 5 <br />Location address: N ✓A1;j71\ fl Suite: <br />City: rA M "C k 11 State: Zip: 61 'S7 33 v' County: <br />Owner/ Contact: S D Sx vq h e j Phone/ Fax: <br />2. BUSINESS NAME: <br />Location address: Suite: <br />City: State: ZiD: Countv: <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 to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: - Date: " I `' y <br />Print Name: Title: <br />FOR OFFICE USE ONLY k <br />Program (PE): _Y1 iaFees: Authorized by (RENS): Date Entered: <br />2 <br />