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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> J 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 MBody Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding QPermanent Cosmetics <br /> II. REQUIR D REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> iMAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2QAnnual Body Art Facility Permit <br /> III.APPLICA IMFORMATION- i <br /> NAME: i1 . )� C G� I VVI Phone: Zocl 39,5 grJS <br /> HOME ADDRESS: ( S v1� Email: J _ 'i <br /> Ci i State: zip: C( L4 2- County: c.✓1 j u c., v l+-A <br /> Date of Birth: Z- ,� Gender: M or M (circle one) <br /> Identification Type: C7jDrIvers License Mother Identification No.: <br /> Facility where <br /> /Body Art Services Will be Provided <br /> Facility Name: Q�c_r-�-e✓� C�, Owner: �v "Ga ev-, <br /> Address ( " c>- i e_ -:E 2_; c_ L/ L n CCS <br /> Evidence of Six-months of Related Experience <br /> Facility Name: ✓1 Lat A Owner: A r <br /> Address: U ur V <br /> Service You Provided: w C7 r V 1 <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Completed: Training Provided by., <br /> Hepatitis B Vaccination Status:Choose One and Submit Documentation <br /> 1MCertification of Completed Vaccination 3[::]Contraindlcated for Medical Reasons <br /> 2[::]Laboratory Evidence of Immunity 417 ccination Declination <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 /> a <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 toest my knowledge and belief the statements made herein are true and correct. <br /> Signature: GZL/ Date: �' 1 <br /> Print Name: ( Title: <br /> EO `OF ICE USE ONLY <br /> �WLA <br /> -rogra (PE) Feeszed by(REHSj Da�e�Entered� . <br />