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San Joaquin County Environmental Health Department 1668 East Hazelton Avenue Stockton, CA 95205 Tel: (209) 468-3420 Fax:(209) 464.0136 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) QTattooing Body Piercing QMechanlcal Stud and Clasp Ear Piercing QBranding ®Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply, 1®Annual Body Art Practitioner Registration 3[:]Mechanlcai Stud and Clasp Ear Piercing Notification 2MAnnual Body Art Facility Permit III. APPLICANT INFORMATION: IV NAME: PL '3, Q Phone: V�'S�• LAcatlon address: Sul[e: City: State: ZID: County: Owner/ Contact: Phone/ Fax: The undersigned hereby 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 requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that t as o qty knowledge and belief the statements me a her In are true and correct. Signature: Date: Print Name: Title: Scanned with CamScanncr M Date of Birth: Gender: F or M (circle one) Identification Type: Drivers License Other Identification No.: Facility where Body Art Services Will be Provided Faclli Name: %Owner: n •- 1 Address: 1`22j rlEjr A!& cW Evidence of Six -months of Related Experience FacilityName: !!II Owner: 1�aSb Address: Service You Provided: Supervisor Name and Contact Information: i Bloodborne Pathog'e'n Trai'-ni'n1g: Submit Certificate n 0� 1n' Date Completed: 4 7 N Tralnln Provided by: OttoVe TrA Hep,,,,,,aa��titi—it,f,,,,iiiffs B Vaccination Status: Choose One and Submit Il ylCertlfication of Completed Vaccination 2 Laboratory Evidence of Immunity Documentation 3QContraindlcated for Medical 4Qvaccination Declination Reasons LAcatlon address: Sul[e: City: State: ZID: County: Owner/ Contact: Phone/ Fax: The undersigned hereby 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 requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that t as o qty knowledge and belief the statements me a her In are true and correct. Signature: Date: Print Name: Title: Scanned with CamScanncr