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San Joaquin County 1869 East nazeltan Avenue <br />Sto95205 <br />Environmental Health Department el: (209)kton, CA -3420 <br />Tel: (209) 468-3420 <br />- Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ , <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCEDU ES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing oBody Piercing Mechanical Stud and Clasp Ear Piercing <br />®Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATYON, PERMIT, OR NOTIFICATEON FEES: Check all that apply. <br />1�Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br />2®Annual Body Art Facility Permit <br />YI: <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: UV�.1OH ,c, �CC.(1 S+',� �l'etrU Wc.t <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <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 />I hereby certify that to the best of rJt]Gt[nowledye and belief the statements �m/ade herein are true and correct. <br />Signature: TC-,.,7 L�� Date: Lt—/3`Z-Z��1 <br />Print Name: � �4.,_,,e Title: L'-Ft*S� <br />FOR OFFICE USE ONLY - - <br />Program (PE): q/10 Fees: d Authorized by (RENS): 6 1 IdC, ii Date Entered: <br />