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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205 <br />Tel: (209) 468-3420 <br />- <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCED RES TO BE PERFORMED: Check all that apply (see back for definitions) <br />glattooing MBody Piercing Mechanical Stud and Clasp Ear Piercing <br />=Branding =Permanent Cosmetics <br />II. REQUI FID REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply, <br />1nnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />II: <br />BODY ART PRACTITIONER ONLY <br />Date of B <br />Gender: <br />F <br />(circle one) <br />Identification Type: rivers License Other <br />Identification No.: <br />f�J) <br />S <br />fo�r�� <br />�Yv <br />Facility where Body Art Services Will be Provided <br />Facility Name: � Qu* <br />Owner: <br />Address: <br />v\ <br />C <br />q� U2 <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />()— I'—� Training Provided b�TMDate Completed: <br />k V1 I <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />Sr'lCertlfication of Completed Vaccination 3r'lContralndicated for Medical Reasons <br />2[= Laboratory Evidence of Immunity 4FO accination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <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 bod art r 'ces or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify t 0 the b f my knowled a and belief the statements made herein are true and correct. <br />Signature: Date: 1"36 � <br />Print Name: Title: O(.y VL.( c <br />OFFICE USE ONLY f / <br />3m (PE): 4110 Fees: Authorized by (REHS): 1 uii� Date Entered: 12-ho/z, <br />