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San Joaquin County 1868 East Hazelton Avenue <br /> i <br /> nVirOnmen$di H@dint Department Stockton,CA 95205Tel: (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 rmanent 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 /> LAJ <br /> 2 Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: �r,�' <br /> NAME: S.. , Phone: ZS - `64- <br /> HOME ADDRESS: 14Email:jig(e1i(( i Ck .0501t" <br /> City: (° State: Zip: qs rs County: <br /> e -e <br /> Date of Birth: Gender: or M (circle one) <br /> Identification Type: Drivers License =10ther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: Owner: <br /> Address: <br /> Eviden -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 Com leted: Training Provided by: bololx 501kx 6 OAS <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 /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: S 3 <br /> Location address: 3 Lj2 {�i J Suite: <br /> City: State: ` Zip: County: SIK <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 the best of my knowledge and belief the statements made herein are true and correct. <br /> Signature: ,Q ,(° Date: <br /> Print Name: Ze5s l ay ij®1'e Title: <br /> v <br /> u <br /> �, f2 <br />