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San Joaquin County . 1868 East Hazelton Avenue <br /> Environmental Health Department <br /> Stockton, CA 9szos <br /> 7�- r 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 /> F—ITattooing =Body Piercing =Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 11,UAnnual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br /> 2=Annual Body Art Facility Permit <br /> IIINAA SPE ICANT INFORMATION: �l ck Phone: H 4\ ? "1 <br /> HOME AD RESS: `VEmail: <br /> Cit C�foState: CA Zi -�Zr' Count <br /> BO RT PRACTITIONER ONLY <br /> Date of Birth: IqHb Gender: Pn or MM (circle <br /> one) <br /> Identification Type: Drivers License Other Identification No.: 162-- 0-IV —E;77-0 <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: <br /> Address: 53 <br /> t <br /> Evidence o oRelated Experience <br /> FacilityName: nths of Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by: <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1F-1Certification of Completed Vaccination 3F'—IContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4EOvaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: oncti-( UA Suite: <br /> Cit State: CA Zip: County: n <br /> I <br /> Owner/Contact: ) � Phone/ Fax: <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 to 1:/b t of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: , C x1� <br /> Print Name: J Title: <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> If 2 <br />