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c° ` San i un 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> a Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing QBody Piercing Mechanical Stud and Clasp Ear Piercing Aj.R <br /> Branding Permanent Cosmetics tiv 182019 <br /> At <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. 'T/$lrzR �. <br /> 1 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification H <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: Ran GreggPhone: 209 373-6525 <br /> HOME ADDRESS: 118750 Olive street Email: N/A <br /> City: Woodbridge State: CA zip: 95258 County: San Joaquin <br /> BODY ART ERACTMONER ONLY <br /> Date of Birth: 05/11/1981 Gender: F or (circle one) <br /> Identification Type: Drivers License Other Identification No.: D212 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Quarter Horse Owner: Geoffrey Rogers <br /> Address: 916 Yosemite St; Stockton CA 95203 <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Stay True Owner: Ryan Groebler <br /> Address: 7453 Amador Valley;Dublin,CA 94568 <br /> Service You Provided: Tattoo Artist <br /> Supervisor Name and Contact Information: Ryan Groebler (925) 479-9333 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: 03/13/2018 Training Provided by: American Red Cross <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> 2EDLaboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Quarter Horse <br /> Location address:916 Yosemite St. Suite: <br /> city Stockton State:CA zip:95203 Countv:SJ <br /> Owner/Contact: Geoffrey Rogers Phone/ Fax: (209) 227-8374 <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 agrees40 operate in accordance with all applicable state and local <br /> requirements governing safe body art pra es or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certif a e beqtdf my k ledg an el' the statements mad herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): () Fees: Authorized by(REHS): Date Entered: <br /> 2 <br />