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San Joaquin County is 1868 East Hazelton Avenue <br /> `= Stockton, CA 95205 <br /> Ita.= Environmental Health Department <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. PROCED S TO BE PERFORMED: Check all that apply (see back for definitions) <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUI5015 REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1 ual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: Phone: �r <br /> HOME ADDRESS: Email: <br /> City: State: Zip: County: <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: ®-Q Q— Gender: M o M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: �M Owner: <br /> Address: / 1 � �— <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: '&— .5-� Training Provided by: rAwL <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1=Certification of Completed Vaccination 31C raindicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: uSuite: <br /> Cit State: Zi : s Count <br /> Owner/Contact: Phone/ Fax: C <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 tification and agrees to operate in accordance with all applicable state and local <br /> require is governing t practices or practices governing mechanical stud and clasp ear piercing. <br /> I h eby certify that t e best of my owledge and belief the statements made herein are true and correct. <br /> Sign e: Date: <br /> Print Name: Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): V ql,.10 Fees: Authorized by (REHS): �� Date Entered: 1'2 L5 <br /> If 2 <br />