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San Joaquin County 1868 East Kazelton Avenue <br />Stockton, CA 95205 <br />Environmental Health Department Tel: (209) 468-3420 <br />Fax: (209) 464-0138 <br />13ODY 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 />CK3Tattooing [3Body Piercing [:3Mechanical Stud and Clasp Ear Piercing <br />[=]Branding [::]Permanent cosmetics <br />11. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1EMAnnual Body Art Practitioner Registration 3[Z]Mechanical Stud and Clasp Ear Piercing Notification <br />2[DAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />vt V3 &k V�"A t Phone: 11-b-1 G 6 1, 0,; � <br /> <br /> <br /> ,,, <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BU$XNEIS NAME: <br />Location address: <br />Suite: <br />M: State: <br />Zip: <br />County: <br />Owner/ Contact: Phone/ <br />Fax: <br />2. BUSINESS NAME: <br />Location address: <br />Suite: <br />Cm; State: <br />Zip: <br />County: <br />Owner/ Contact: Phone/ <br />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 my kn >acl dge and belief the statements made herein are true and correct <br />Signature: - &Aal—� Date: '-.12 <br />Print Name: j)4C6V-- L1)A1WK,0( Title: <br />