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San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Environmental Health Department Tel: (209)46B-3420 <br />28x 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 />attooing E313ocly Piercing ®Mechanical Stud and Clasp Ear Piercing <br />®Branding ®Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />IEgjALwual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />20Annual Body Art Facility Permit <br />III. APPLICANT IIJFORMATION., QQ J <br />NAME: I n �) I 1 t e Phone: 1 '. -1 <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: Gender: F or rM (circle one) <br />Identification Type: Drivers License (Other Identification No.: <br />Facility where Body Art Services will b Prov' ed Fl <br />Facilitv Name: 1 l Owner: e. l <br />Evidence of Six -months of Related <br />Owner: <br />M <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: - <br />Hepatitis <br />:Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1 Certification of Completed Vaccination 3 MContraindicated for Medical Reasons <br />2 Laboratory Evidence of Immunity accination Declination <br />IV. FACILITY LOCATION (S): (Attach addityonal shpktts as necessary) <br />Locationad ess: JILD c /r BB Suite: <br />> <br />Citv: ! 1 ( State: Y ZiD: !� 1) County: C\ <br />Owner/ Contact: Jfl UV N-` K,? Y V1 t/"' VTPhone/ Fax: V -1 J W i <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 thalk to the best of my knowledge and belief the statements made herein are true and correct. <br />Signature: te: <br />Print Name: , It c (7l taW, Title: <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (RENS) Date Entered: <br />