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0 San-3oaquln County i <br /> 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental t Department Tel:(209)466-3420 <br /> Fax:(209)4 0138 <br /> FACILITYBODY ART T / <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I.PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> att ing Body Piercing EDMechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II.REQUIRED REGISTRATION,PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 112gAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> Annual Body Art Facility Permit <br /> III."PLICANT INFORMATION, <br /> NAME: Phone: \' <br /> HOME ADDRESS: ail; <br /> Ci S to Zin, County., <br /> YPCrITID W61" <br /> Date of Birth: Gender, F or (circle one, <br /> Identification MADrIvers Ucense [:30ther Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: I—YAL <br /> ner: 1 <br /> Address: r <br /> Evidence o s of Related Experience <br /> Facility Name: Owner: <br /> A <br /> Service You Provided, <br /> SuDervisor Name and Contact Info ation. <br /> Bloodborne Pathogen inin :Su it Certificate <br /> Date Com let Trainin Providbv: oubQy <br /> Hepatitis a in on s:Choose One and Submit Documentation <br /> 1E3CertMcatlon of Completed Vaccination 3[MContraindicated for Medical Reasons <br /> 2MLaboratory Evidence of Immunity 4 vaccination Dedination <br /> .FACILITY LOCATION( ):(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 add Suite: <br /> City: State: <br /> Zip: County: <br /> Owner/Contact: one/Fax, <br /> The undersigned hereby applies fora 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 h W co 1 e and beliefthe statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: le: <br /> f2 <br />