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*1.11`1111 <br />San Joaquin County 1868 East Hazelton Avenue <br />95205 <br />Environmental Health De artment Stockton)46 -3420 P Tel: (209} 468-3420 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 ORFc g <Wdoina <br />Etol� fi Permanent Cosmetics P V -e% <br />II. REUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />i Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br />2[_]Annual Body Art Facility Permit <br />II: <br />Date of Birth: tkGender: F or (circle one) <br />Identification Type: tRaDrivers License Other Identification No.: -F2 d ro-LZ (d <br />Facility where Body Art Services Will be Provided PP <br />FacilityName?✓1 2- 1 Owner: cr - 9a, "ems vl <br />Address: 2� hvi Ca. <br />Evidence of Six -months of Related Experience <br />Facility Name: z- Owner: i vii`Ltiv <br />Address: 1�A c- J Ll <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate CAI <br />Date Com feted: / Training Provided b : <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1 Certiflcation 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 neypa Bary) <br />RM <br />K9 <br />L. fiUJ11YGJJ axrc: <br />►V�� Location address: Suite: <br />i� 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 Focal <br />requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify tot b t of my knowledge and belief the statements made herein are true and correct. <br />Signature: ✓ 1v� Date: '2511 Z <br />Print Name: i vA Title: <br />A ute lyt� <br />