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San Joaquin County1868 East Hazelton Avenue <br /> e Stockton,CA 95205 <br /> 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. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> ID Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION 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 /> III.APPLICANT INFORMATION: <br /> in NAME: \L Phone: C2 <br /> <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: — '— 141WIX Gender: (circle one) <br /> Identification Type: EEDrivers License MOther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: 'F®r Owner: b l <br /> Address: \ 1 • $ <br /> s Evidence of Six-months of Related E erience <br /> Facility Name: C C0 Owner: vicbsom <br /> Address: 0 22 <br /> Service You Provided: <br /> Supervisor Name and Contact InformatiL, t <br /> Bloodborne Pathogen Training: Submit Certifi e <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3®Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4ERraccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: IS500 K% , uite: <br /> P <br /> Cit St te: 02.Ck Zi ount : <br /> Owner/ Contact: \ Phone/ Fa <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 b d art pr ctices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify be y k o ge and belief the statements made herein are true and correct. <br /> Signature: Date: eN_ J <br /> Print Name: S 'G Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> If2 <br />