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San Joaquin County 1868 East Hazelton Avenue E95205 nvironmental Health Department StocktonCA PTel: (209)) 468--34203420 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 Body Piercing r7mechanical Stud and Clasp Ear Piercing Branding ®Permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. 1 lfAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification 2MAnnual Body Art Facility Permit III. APPLICANT INFORMATION: . BODY ART PRACTITIONER ONLY IV. FACILITY LOCATION (S): (Attach additional sheets as necessary Date of Birth: (1 r) '�71' ' Facility where Body Art Services Will be Provided Facility Name: O On do joh ('(i Owner: GI � /U I ry Address: 0M 1 Evidence of Six -months of Related Exp6�erri�reence� � �o �! •� n FacilityName: A�Q IDE IX ule:: '"t Owner: LiirZAA IN I J Address: i is Prve• (n� --ee,, U f:k Service You Provided: M I G('n LA 0 l ei ' Supervisor Name and Contact Information: PizP IN I �oq 63 PJ 5 Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation 1r"ICertification of Completed Vaccination 3r'lContraindicated for Medical Reasons 2[:3Laboratory Evidence of Immunity 4�Vaccination Declination Owner/ Contact �I��AI •� Phone/ Fax• 2, BUSINESS NAME: Location address: Suite: City: State: Zip: 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 to the best of my knowledge and belief the statements made herein are true and correct. Signature:•�'1 L'�-� Date: Print Name: lflG( ii %� l . Z Title: FOR OFFICE USE ONLY ( Program (PE): IIS() Fees: jf � Authorized by (REHS): 690 Date Entered: )h A ) a„QTM=CQ WA F. Owner/ Contact �I��AI •� Phone/ Fax• 2, BUSINESS NAME: Location address: Suite: City: State: Zip: 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 to the best of my knowledge and belief the statements made herein are true and correct. Signature:•�'1 L'�-� Date: Print Name: lflG( ii %� l . Z Title: FOR OFFICE USE ONLY ( Program (PE): IIS() Fees: jf � Authorized by (REHS): 690 Date Entered: )h A