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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 />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />TattooingBody Piercing =Mechanical Stud and Clasp Ear Piercing <br />r-11611 1:3 <br />Branding Permanent Cosmetics <br />J _w <br />Uo <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. P'O� �J <br />i Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notificatio ® ` \ <br />2 Annual Body Art Facility Permit <br />III. APPLICANT I <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: l0 9 <br />Gender: F or (circle one) <br />Identification Type: [ElDrivers License Other <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: �� <br />Owner: 1^' <br />Address: <br />Evidence of Six -months of Related Experience <br />Facilit Name: L <br />Owner: <br />Address: <br />Service You Provided: A / T a a <br />Supervisor Name and Contact Information: <br />o <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed:I Ilk Training Provided by: &Oe 1 <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 ad/diitional sheets as necessar ) <br />1. BUSINESS NAME: C 4 1 <br />Location address: 1,570 e_ Suite: <br />Citv: KGs LI State: ZiD: Countv: <br />1FAM-104 <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 certifyt" the best of my)cnowledge and belief the statements made herein are true and correct. <br />Signature: j Date: <br />Print Name: ✓1 �,® Title: <br />FOR OFFICE USE ONLY l <br />Program (PE): fi Fees: t Z j Authorized by (RENS): Date Entered: <br />