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�M <br />V� <br />�. c,6 <br />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 />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 r7mechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1MAnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br />2FIMAnnual Body Art Facility Permit <br />III. AP <br />1—Fi l;•7 � A <br />Date of Birth: Gender: F F^1 otqLaJ2 (circle one) <br />Identification Type: FADrivers License MOther Identification No.: 7 <br />Facility where Body Art Services Will be Provided <br />Facility Name: WN Owner: 1501 <br />Address: Z P&ck G A-V VbL Cts - U <br />Evidence of Six -months of Related Experience <br />FacilityName: Z I T� ` I[_ Owner: f r <br />Address: 2 V2 ntba Au7 2 <br />Service You Provided: `TCA D(7 S <br />Name And Contact Info <br />Pathogen Training: Submit Certificate <br />ate Completed: Training Provided by: <br />epatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity 4[::]Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: S I V 5 L) N Tq. i' l oo <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: <br />Print Name: <br />Date: <br />Title: G`F`h6U S' <br />4 <br />