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Vasil San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205 <br />Tel: (209) 468-3420 <br />'- <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 />Tattooing ED Body Piercing r7Mechanlcal Stud and Clasp Ear Piercing <br />Branding M Permanent Cosmetics <br />II. REQUIRED REG%STRATIONI PERMIT, OR NOTYFICATYON FEES; Check all that apply. <br />1f'7,lAnnual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification <br />2f'lAnnual Body Art Facility Permit <br />II <br />IV <br />BODY ART PRACTITIONER ONLY <br />Date of <br />Gender: M or <br />M (circle one) <br />Identificatlon Type: <br />L:aDrivers License Other <br />Identification No.: <br /> <br />Facility where Body Art <br />,rSrtvic-es V4111 be Provided <br />Facility Name: /7l,/ 0 <br />wner: <br />Address: V, <br />1t <br />-/0 ,✓� <br />Evidence of Six -months of Related Experience <br />Facility Name: 'rte �` <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />— <br />— 3&3 <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: 3 /�lt) 1 Uz Training Provided b <br />Hepatitis.B Vaccination Status: Choose One and Submit <br />1MCertificatlon of Completed Vaccination <br />2[DLaboratory Evidence of Immunity <br />Documentation <br />3MContra indicated for Medical Reasons <br />4V=accination Declination <br />Owner/ Contact: Phone/ Fax• <br />The undersigned hereby applies for a Body Art Facility Permit and/or Praconer Registration and/or Mechanical <br />Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local <br />requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify that o� thg best of Fyly knowledge and belief the statements made herein are true and correct. <br />Signature: l/1�✓AI/t'l1CA&4Date: <br />Print Name: Ga ty, Il Title: a� / o iff6jigr <br />FOR OFFICE USE ONLY <br />Program (PE): 4110 Fees: �ISZ Authorized by (REHS): ���� Date Entered: 3/30111 <br /> <br />