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AWLA San Joaquin County 1868 East Hazelton Avenue <br /> 95205 <br /> Environmental Health Department Stockton CA <br /> Tel: (209)468-34203420 <br /> 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 /> QTattooing OBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1 Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: �n /(11 Phone: n <br /> HOME ADDRESS: oiV7 f6� IC C'01A"Vt Email: IM,II 1AA C'-AICN LiJ:tffD . <br /> City: State: 0A zip: County: <br /> BODY ART PRACTITIONER ONLY <br /> '7, <br /> Date of Birth: (9I -/I Gender: 6 F or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: <br /> Address: 1114 CA 0a� <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: 2 <br /> Service You Provided: pig C'l <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed; Trainingi Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1[tCertlfication of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2[:3Laboratory Evidence of Immunity 4[DVaccination Declination <br /> IV. FACILITY LOCATION (5):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: C <br /> Location address: 97 e��' '1„^' ' •t-Fn^^yin PN 1 4 Suite: <br /> City; n State: Zip: g6AD I-�1 Coun : G1 LLU, <br /> Owner/Contact J_kX 00 nn \ I_-.. Phone/Fax: oQ FJGI f—i I �i2+-0 2, l <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:t the best of m knowledge and belief the statements made <br /> /herein are true and correct. <br /> Signature: Date: i" I a 4020 ` t - <br /> Print Name: 43 4 Title: <br /> ti41y,l/ <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by(REHS): Date Entered: <br /> 2 <br />