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San Joaquin County 1868 East Hazelton Avenue <br />Environmental Health Department Stockton, CA 95205 <br />!exI Tel: (209) 468-3420 <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ I <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />"Tattooing Body Piercing LjMechanlcal Stud and Clasp Ear Piercing <br />Branding EE!Permanent Cosmetics <br />II. REQUIR D REGISTRATIONPERMITOR NOTIFICATION FEESChk l <br />I A , , ; ecaltfiat apply. <br />nnual Body Art Practitioner Registration 3F7Mechanical Stud and Clasp Ear Piercing Notification <br />2[::]Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: _, <br />.BODY ART PRACTITIONER ONLY <br />IV. FACILITY LOCATION (S): (Att <br />!e <br />Date of Birth: z" I �J. I �'� <br />Gender: F or M (circle one) - <br />Identificatlon Type:Drivers License MOther <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />2 <br />'Facilit Name: Aik <br />Owner: <br />^ <br />Address: ZZ) . W . d �..0 L <br />Evidence. of Six -months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination <br />3MContra indicated for Medical Reasons <br />2[' ]Laboratory Evidence of Immunity <br />4Vaccination Declination <br />ach additional sheets as necessary) <br />Location adtlress: Suite• <br />City; Sta to Zip• on y: <br />Owner/ Contact: Phone/ Fax: <br />2. BUSINESS NAME: <br />Owner/ Contact; _ Phone/ Fax <br />The undersigned hereby applies for a Body Art Facy Permit and/orPractitioner 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 studand clasp ear piercing. <br />I hereby certify th to the best of my knowledge and belief the statements made herein are trruue' and correct. <br />Signature: Date: jMV. Y� 1►' /J�+ ZZ. <br />Print Name: ` Y, <br />le: <br />OFFICE USE ONLY <br />3m (PE): p/ (I t, Fees: L f.5 c <br />2 <br />Authorized by <br />(RENS): <br />61 n1 (s la Date Entered: <br />