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San Joaquin County 1868 East Hazelton Avenue <br />StoEnvironmental Health Department el: (209)kton, 46 95205 <br />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. PROCED S TO BE PERFORMED: Check all that apply (see back for definitions) <br />aTattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br />Branding [:]Permanent Cosmetics <br />II. REQUIR EGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />i Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />20Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: i <br />NAME: "R i( IVi.A4 T. ALA <br />LA IQ r Phone: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Q COA <br />FAI <br />