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San Joaquin County • 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA 95205 <br /> yr, 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 MMechanical Stud and Clasp Ear Piercing <br /> ElBranding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> 1r!;&nnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br /> 2Annual Body Art Facility Permit <br /> III.APPLICA INFORMATION: <br /> C, � <br /> Phone: 2C / <br /> <br /> <br /> f BODY ART PRACTITIONER ONLY <br /> Date of Birth: — 2 — ( Gender: F I or (circle one) <br /> Identification Type: ZEgDrivers License MOther Identification No.: <br /> <br /> Facility where Body Art Pr Services Will be Pided <br /> Facility < {Name: G{ C � 0C,� C) Owner: <br /> Address: <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 /> 1F-1Certification of Completed Vaccination 3r--JContraindicated for Medical Reasons <br /> 2[:DLaboratory Evidence of Immunity 4 �C"Vaccination 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 /> 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 tjaat to the brzz!g� <br /> y knowledge and belief the statements made herein are true and correct. <br /> Signature: a� � _ Date: <br /> Print Name: <br /> •'t� Title: <br /> FOR OFFICE USF ONLY <br /> Zoo ^t.r <br /> Program (PE): O Fees: _ Authorized by (RENS): .-CAA ate Entered: <br /> If2 <br />