HomeMy WebLinkAboutbodyartpractitionernoticeofseparationBody Art Program
Alameda County Department of Environmental Health
Solid/Medical Waste Management
1131 Harbor Bay Parkway, Alameda, CA. 94502 Phone: (510)567-6790 Fax: (510) 337-9234
https://deh.acgov.org/index.page
BODY ART PRACTITIONER
NOTICE OF SEPARATION FORM
FOR OFFICIAL USE ONLY
TO: Alameda County Department of Environmental Health RE: PRACTITIONER SEPARATION FROM BODY ART FACILITY
This is to notify Alameda County Department of Environmental Health that the following body art practitioner(s) is/are no longer working at this facility and is/are no longer an employee(s) at this location. NAME OF PRACTITIONER (PRINT): DATE OF SEPARATION: (mm/dd/yyyy) NAME OF PRACTITIONER (PRINT): DATE OF SEPARATION: (mm/dd/yyyy)
FACILITY OWNER’S SIGNATURE: DATE: (mm/dd/yyyy)
PRINT NAME / TITLE:
FA# PR#
ENVIRONMENTAL HEALTH SPECIALIST:
APPROVED NOT APPROVED DATE: (mm/dd/yyyy)
FACILITY INFORMATION
FACILITY NAME: FACILITY ADDRESS: CITY: STATE: ZIP CODE: FACILITY EMAIL ADDRESS: FACILITY PHONE NUMBER: