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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 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. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing <br />Branding Permanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. � <br />SQAnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br />2[DAnnual Body Art Facility Permit <br />BODY ART PRACTITIONER ONLY <br />Date of Birth:. Gender: <br />r <br />M (circle one) <br />Identification Type: Drivers License rlother Identification No.: <br />Facility where Body Art Services Will be Provided <br />FacilityName: SA1-M 00 r'EUZ�W Owner: L.Orz v� Ti <br />�d W AM))) <br />Address: GI -FIG '10 NU -C OagTOA/ <br />Evidence of Six -months of Related Experience <br />FacilityName: I�� Y`— SE��yL G�"ii Owner: /zR-uv 71 <br />(//� � %U <br />` <br />Address: 1q&1fo01G -AUMCC <br />Service You Provided: <br />Supervisor Name and Contact Information: Edi IeLlei 7Y h <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity 4EEyaccination Declination <br />IV. <br />Location address: Suite: <br />City: State: Zip: County: <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 />FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify thajr to the b sE f my knowledge and belief the statements made herein are true and correct. <br />Signature: Date: !2 Org <br />Print Name: Title: <br />FOR OFFICE USE ONLY <br />(PE): .ill () Fees: Of 94ufthorized by (RENS): 3(u(yW Date Entered: <br />