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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <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 /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification <br /> 2 Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION., <br /> NAME: a Phone: <br /> HOME ADDRESS: C- Email: <br /> Ci State: CIA Zi County: <br /> h: �> BODY ARTPRAGTRTIONER ONLYt <br /> . RIM <br /> gr <br /> Date of Birth: c - s — Gender: Inor 0 (circle one) <br /> Identification Type: Ishrivers License Mother Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> -I— <br /> Facility Name: Owner: 16N D r ik 1)C) <br /> Address: 012. W . L <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: 1:1Training 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 4 Vaccination Declination <br /> L_ L11=1 <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <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 t at .o the best my kno dg nd belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: tril if <br /> FO O IGE <br /> "S 53 � � 2 % 1"I"!"! <br /> �rpg a PES. Fees Aut o izedb (REHB � s DaLim <br /> w 'f2 <br />