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San Joaquin County/ 0 1868 East Hazelton Avenue Department Stockton, 46 -3220 Environmental Health De P Tei: (209) 468-3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) fattooing Body Piercing ®Mechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. i Annua) Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification 2 Annual Body Art Facility Permit N M Date of Birth: / Gender: F -or M (circle one) Identification Type: Drivers License MOther Identification No.: Facility where Body Art Services W"I a Provided az6e Facilit . Name: jLX Owner: (Evidence of Six -months of Related Experience a I Facilitv Name: Owner: matron: Submit Certificate Hepatitis B Vaccination Status: Choose One and Submit Documentation 1®Certification of Completed Vaccination traindicated for Medical Reasons 2®Laboratory Evidence of Immunity Vaccination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 1. BUSINESS NAME: SIF Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: 2. BUSINESS NAME. Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notificati n and agrees to operate in accordance with all applicable state and local requirements governing saf ody art pr ices or practices governing mechanical stud and clasp ear piercing. I hereby certify t b st owledge and belief the statements made berellryare true and correct. Signature: Date: Print Name: VTitle: