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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton) 46 3220 <br />� Tei: (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 ES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing MBody Piercing MMechanical Stud and Clasp Ear Piercing <br />Branding MPermanent Cosmetics <br />II. REQUIVID REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />20Annual Body Art Facility Permit <br />iii. AP I ''I' IPlEQR[4(►TlON C1 Phone:N10� — Z— Cif <br />NAME:E:L �f11��� <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />51-LI514 <br />C. <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: State: <br />Zip: <br />County: <br />Owner/ Contact: Phone/ <br />Fax: <br />2. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: 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 of my knowledge and belief the statements made herein are true and correct: <br />Signature: Date: <br />Print Name: Title: <br />