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o , <br /> San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department 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 /> Branding Permanent Cosmetics <br /> II.REQUIRgP REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i 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 /> NAME: r 1 rL Phone: 0 a e <br /> HOME ADDRESSEmail:-: JJ <br /> Cit State: CA Zip: `l Coun : <br /> .r..7.7,77 <br /> Date of Birth: � ' 6 `� b Gender: F or M (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided y <br /> Facility Name: Owner: 16( <br /> Address: ,;D <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 Trai ing:Submit Certificate <br /> Date Com leted: D Training Provided by: t <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3®Contra indicated for Medical Reasons <br /> 2 laboratory Evidence of Immunity 4 F124accination Declination <br /> IV.FACILITY LOCATION (S):(Attach additio al sheets as necessary) <br /> 1 BUSINESS NAME Q 11 <br /> Location address: D L &It Suite: <br /> City ' State• c pr Zip County: <br /> Owner Contact: r MIALa Phone Fax: — <br /> 2.BUSINESS NAME: <br /> Location address: Suite: <br /> City State: ziaL 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 tha the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name `"r� s1�.��Y'I <br /> Title <br />