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San Joaquin County 1868 East Hazelton Avenue Environmental Health Department s odann, CA 95205 Tel: (209) 468-3420 " Fax: (209) 4640138 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) Tattooing ®Body Piercing Mechanical Stud and Clasp Ear Piercing Branding MPermanent cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES; Chetk all that apply. 1MAnnual Body Art Practitioner Registration 3F'lMechanical Stud and Clasp Ear Piercing Notification 2®Annual Body Art Facility Permit II IV. FACILITY LOCATION BUSINESS NAME: additional sheets as .1. Location ad(d�r/Iess; 23Q� V Suite: /1/� City: p IT State: Zill: Mri12 Count : trt Owner/ Contact: J Phone Fax: ZQ `I Location address: Suite: State: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a FOR OFFICE US� ONLY grogram (PE): [�/: 0 Fees: /rjal`4� Authorized by (KERS): i2 BODY ART PRACTITIONER ONLY Stud and Ear Piercing Date of B agrees to operate in accordance with all applicable state and local Gender: F M (circle one) Identification Type: Drivers License Other rr Identification No.: Facility where Body Art Services Will be Provided. FacilityName: ' o I �I \ �' S Owner: 1 �1 oun Address: 23010 ^tvin, Date: oFSix u Facility Name: 4 xp` Owner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Date Completed: Certificate Trainino Provided by; Hepatitis B Vaccination Status: Choose One and Submit 1r'lCertification of Completed Vaccination 2[:]Laboratory Evidence of Immunity Documentation 4"IContramnicated for Medical Reasons 4©Vaccination Declination IV. FACILITY LOCATION BUSINESS NAME: additional sheets as .1. Location ad(d�r/Iess; 23Q� V Suite: /1/� City: p IT State: Zill: Mri12 Count : trt Owner/ Contact: J Phone Fax: ZQ `I Location address: Suite: State: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a FOR OFFICE US� ONLY grogram (PE): [�/: 0 Fees: /rjal`4� Authorized by (KERS): i2 Body Art Facy Permit and%or Praditloner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements gover g sa body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify th best of my knowledge and belief the statements made herein are true and correct. Signature: Date: Print Name: 4 xp` /wt')Title: 1306716.( 01er (jtr ({(`Date Entered;