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San Joaquin County 1868 East Hazelton Avenue jEnvironmental Health Department Stockton, CA 95205 Tel: (209) 468-3420 ` Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDU S TO BE PERFORMED: Check all that apply (see back for definitions) Tattooing OBody Piercing MMechanical Stud and Clasp Ear Piercing MBranaing MPermanent Cosmetics II. REQUIRED REGISTRATIONI PERMIT, OR NOTIFICATION FEES: Check all that apply. Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification 2f�jAnnual Body Art Facility Permit III. APPLICANT INFORMATION: Date of Birth: Q61Q 7" Gender: F or (circle one) Identification Type: rivers License Other Identification No.: Facility where Body Art Services Will be Provided mss.. FacilityName: saarfT CiNr e. �" 1 \ oQ Owner: Coen Riniglers ct Address: 1 1 N 0 15e. ml 'fes 5 Evidence of Six -months of RelatedExperience _ Facility> Name: tArv\�. a a .Q, Owner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Completed: Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation 1®Certificatlon of Completed Vaccination 3 =Contra indicated for Medical Reasons 2MLaboratory Evidence of Immunity 4®vaccination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) BUSINESS Owner/ Contact: - Phone/ Fax: 2. BUSINESS NAME: City: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner State Zip' County' (PE); o((( (j Fees: 9/5 L Authorized by Owner/ Contact: phone/ Fax: 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 a t practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to the best of my knowledge and belief the statements m de her in are true and correct. Signature: _ / ((fy�, Date: �ZZ Print Name: S 7 amp. S Cn hLkyi Title: FILE USE ONLY (PE); o((( (j Fees: 9/5 L Authorized by (KERS): Date Entered: