HomeMy WebLinkAboutbodyartpractitionerregistrationcardreplacementformBody 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
REGISTRATION CARD REPLACEMENT FORM
SIGNATURE: DATE: (mm/dd/yyyy)
PRINT NAME / TITLE:
Signature on this form indicates agreement to comply with applicable statutes. Fee is in accordance to Title 6 of the Alameda County General Ordinance Code.
FOR OFFICIAL USE ONLY
Please use this form when requesting a replacement Body Art Practitioner Registration Card that has been lost, stolen, or damaged. A fee will be assessed for a replacement card.
PRACTITIONER NAME (PRINT): FACILITY NAME: FACILITY ADDRESS: CITY: STATE: ZIP CODE: HOME ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: PHONE NUMBER:
FA# PR#
AMOUNT PAID: DATE PAID: (mm/dd/yyyy)
ENVIRONMENTAL HEALTH SPECIALIST:
APPROVED NOT APPROVED DATE: (mm/dd/yyyy)
PRACTITIONER INFORMATION
LOST STOLEN DAMAGED
REASON FOR REPLACEMENT CARD