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San Joaquin County 1868 East Hazelton Avenue Environmental Health Department Stockton, CA 95205 Tel: (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) Tattooing r7l3ody Piercing r7mechanical Stud and Clasp Ear Piercing Branding ®'Permanent Cosmetics II. REQUIREg REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1i Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification 2[DAnnual Body Art Facility Permit II: IV. FACILITY LOCATION (S): (Attach additional sheets as necessary BODY ART PRACTITIONER ONLY Date of Birth: 67M L one) Identification Type: MDrivers License MOther Identification No.: () - Facility where Body Art Services Will be Provided Facility Name:�-1 L0 p k3 t✓L�Z� Owner: LORP�I/4u I/ fS Address: 4d AC. i r/c llwai tAGk, Evidence of Six -months of Related Experience Facili Name: NSAt-1)N IDE �! 1-6 RPAti Owner:/ Address: ;61 P A% c! (/�!C/l.l - S� GkTo f(J Service You Provided: l o� Supervisor Name and Contact Information: 4L A Q Bloodborne Pathogen Training: Submit Certificate ry17� Y�,� C6t/'l)(l fi Date Com feted: " .Zt7 ? Z TrainingProvided by: f�t'l r (Cid Hepatitis B Vaccination Status: Choose One and Submit Documentation IMCertification of Completed Vaccination 3 Contraindicated for Medical Reasons 2[:DLaboratory Evidence of Immunity 4�Vaccination Declination Cites_ �1�Gr-K'1 �N state ('r� Zio%s��k'� countyr Cf�X�,��!��C Owner/ Contact: ��' f7 1 4J .T %( Phone/ Fax' 2. BUSINESS NAME: Location address: Suite: City: State: Zio' County' Owner/ Contact: Phone/ Fax: The undersigned hereby OFFICE USEONLY Cl c1 r l�I& applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical ) agrees to operate in accordance with all applicable state and local equirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. t t t I hereby certify thage Cites_ �1�Gr-K'1 �N state ('r� Zio%s��k'� countyr Cf�X�,��!��C Owner/ Contact: ��' f7 1 4J .T %( Phone/ Fax' 2. BUSINESS NAME: Location address: Suite: City: State: Zio' County' Owner/ Contact: Phone/ Fax: The undersigned hereby OFFICE USEONLY Cl c1 r l�I& applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local equirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. t t t I hereby certify thage o -best of n9y tnowled and belief the statements made herein are true and correct, Signature: Date:�- Print Name: (, PH iu-I i(,b % Title: Fees: �SL Authorized by (REHS): �N �b Date Entered: I I�1%L