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San Joaquin County <br />Environmental Health Department <br />� a' F r � c r •: � • <br />1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Tel: (209) 468-3420 <br />Fax: (209) 464-0138 <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing ElBody Piercing Mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />12 Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: r Phone: (2-0A)2_r <br />HOME ADDRESS: ` Y Email: O <br />City: (i State: Ut Zi 52-oc. Count u <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: Gender: F or (circle one) <br />Identification Type: Drivers License Other Identification No.: <br />Facility where Body Art Services Will be Provided <br />FacilityName: Y ,atmo Owner: <br />Address: <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: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1 Certification of Completed Vaccination Sontrainclicated for Medical Reasons <br />2 Laboratory Evidence of Immunity accination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: p1A Suite: <br />city: State: C�kZi County: OEC► <br />Owner/ Contact: Phone/ Fax: 2_ 4� 1 _ 0 qi-K <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: Date: 1bint <br />Print Name: 11 n wyl a em -6- Title: <br />FOR OFFICE USE ONLY <br />Program (PE): L 1119 Fees: -*IC52— Authorized by (REHS): Date Entered: <br />2 <br />