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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 96205 <br />1 / P 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 />CTattooing Body Piercing MMechanlcal Stud and Clasp Ear Piercing <br />Branding MPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICAT%ON FEES: Check all that apply. <br />1[nAnnual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br />2r'lAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: IM2, L2&y 1010. i Phond:q.04q / y 67 —j 73 <br /> <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: 3//-3/493 <br />Gender: 1Eor em(circle one) <br />Identification Type: roCrivers License MOther <br />Identification No,: <br />Facility where Body Art Services Will be Provided <br />'FaclIIt Name: 1 11lIa)e�S <br />1 <br />Owner: fTT <br />Address: <br />practices or practices governing <br />1 <br />(Xi Q <br />Evidence of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />I Z&/ /% ) <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided <br />by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination 3=Contra Indicated for Medical Reasons <br />2[=]Laboratory Evidence of Immunity 4=Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />1. BUSINESS NAME: <br />Location address: Suite: <br />City: Stater Zip: County: <br />Owner/ Contact: phone/ Fax <br />The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br />Stud and Ear Piercing Notification <br />OFFICE USE ONLY <br />3m (PE): K 11 Fees: 4% (5 ,2 Authorized by (KERS): At <br />and <br />agrees to operate in accordance <br />with all applicable state and local <br />requirements <br />governing safe body art <br />practices or practices governing <br />mechanical stud and clasp ear piercing. <br />I hereby cc'r <br />tl at to the best of my <br />knowledge and belief the statements made herein are true and correct, <br />Signature: <br />Date: <br />I Z&/ /% ) <br />Print Name: <br />Title: <br />u � tl Date Entered: <br />