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San Joaquin County Environmental Health Department 1868 East Hazelton Avenue 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. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) OTattooing [:]Bo ercing Mechanical Stud and Clasp Ear Piercing Branding ermanent Cosmetics II. REQUIRE REGISTRATION, PERMIT, Huai Body Art OR NOTIFICATION FEES; Check all that apply. Gender: F or (circle one) Identification Type: r7fcrivers License Other 1 Facility where Art Services Will be Provided Annual Body Art Practitioner Registration 3[::]Mechanical city �t/�f�nnl"✓•cW��(�..E,(�1,!i'7S Stud and Clasp Ear Piercing Notification ) Facility Permit III. APPLICANT INFORMATION: Phone•"la�'Ta�COe�-' I BODY ART PRACTITIONER ONLY Date of Birth: O(.v ) (9 2 1 Gender: F or (circle one) Identification Type: r7fcrivers License Other Identification No.: Facility where Art Services Will be Provided -Boody FacilityI Name: li St.O si^g"^ t city �t/�f�nnl"✓•cW��(�..E,(�1,!i'7S Owner: Address: ) J l� • -op 117 ht-L�C�I Li �Y JI ii �-�L '� "V�' Evidence of Six -months of Related Experience Facility Name: Owner: Address; Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Completed: v(� w a Training Provided by: 610 i eDIL Dos Hepatitis B Vaccination Status: Choose One and Submit Documentation I Ce kation of Completed Vaccination 3MContraindlcated for Medical Reasons 2M aboratory Evidence of Immunity 4[DVaccination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 2. BUSINESS NAME: Location address: _ Suite: City: State: Zip: County; undsigned hereby The erapplies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notifcation and agrees to operate iii accordance with ali applicable state and local requirements gover ing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify th ,,.to tt�he bes of my knowledge and belief the statements made herein are true and correct. Signature:. '+ Date: CR ((pa.) Print Name: I n t.ra:5.;kTitle: A R 7 1 S j FOR OFFICE USE ONLY Program (111 H 110 Fees: 415,2 Authorized by (RENS): M11,tGN Date Entered: