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San Joaquin County 1868 East Hazelton Avenue 68--34203420 A 9S205 Environmental Health Department Stockton, Tel: (209) 468-3420 46 P .... Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PRO,,,CE___DURES TO BE PERFORMED: Check all that apply (see back for definitions) Tattooing Body Piercing Mmechanical Stud and Clasp Ear Piercing Branding Permanent Cosmetics II. RERED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Cheall that apply. i Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification 2 Annual Body Art Facility Permit BODY ART PRACTITIONER ONLY Date of Birth: 02 111C`{' Gender: F r MM (circle one) Identification Type: WDrivers License rOther Identification No.: Facility where Body Art Services Will be Provided Stud and Ear Piercing Notification and Facility Name: AW4> GA V�.. &Agq Owner: 6v\ Address: ZfestN�IEA 196wkylqcr' " lf�A%) Evidence of Six -months of Related Experience mechanical stud and clasp ear piercing. W� est of my FacilityName: �L., Owner: Address: ZZZ l O✓Wc1 'IF ':::N C.1/kc �ZoZ Service You Provided: Print Name: - Supervisor Name and Contact Information: Title: Bloodborne Pathogen Training: Submit Certificate �y/9/•{-�f-j Date Completed: //v Training Provided by:: V1 I Hepatitis B Vaccination Status: Choose One and Submit Documentation 1MCertification of Completed Vaccination 3 Contraindicated for Medical Reasons 2QLaboratory Evidence of Immunity 4 accination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 2. BUSINESS NAME: Cit': State: ZIp: COUnty: OFFICE USEu ONLY // am (PE): Iiia Fees: Authorized by (RENS): CHQO Date Entered: 1h) '1.'? 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 tha est of my knowledge and belief the statements made herein are true and correct. Signature: Date: � 6 / ZO o�Z Print Name: - Title: �y/9/•{-�f-j (SYi.Q.v r�'t�c{- ck - .