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a, San Joaquin County 1868 East Hazelton Avenue <br />95205 <br />Environmental Health Department Stockton, CA <br />�'. P Tel: (209) 468-3420-3420 <br />,.E <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br />I. PROCED RES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br />=Branding Permanent Cosmetics <br />II. REQUD REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1 Annual Body Art Practitioner Registration 3=Mechanical Stud and Clasp Ear Piercing Notification <br />2 Annual Body Art Facility Permit <br />III. APPLICANT <br />/INFORMATIO�NJ:.�i p / G� / 2� <br />NAME: `�Yl�lif tl/it�// !/ �0�� <br /> <br /> <br />IV <br />BODY ART PRACTITIONER ONLY <br />o the best of m--�y�7���k-{�npp��wledge <br />p <br />Date of Birth: 0(1 � 6 <br />Gender: F or MM (circle one) <br />Identification Type: MDrivers License M Other <br />Identification No.: <br /> <br />Facility where Body Art Services Will be Provided <br />FacilityName: Y a. arO �O <br />Owner: <br />/ /1 <br />61�( A& 6 <br />Address: <br />D <br />• PI hkt S+ <br />D <br />/, /�I ((rr� <br />Uk- 95V6 <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 �T�//raining: Submit Certificate <br />Date Completed: �:U ' Z Training Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documents on <br />1F'j Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2[:]Laboratory Evidence of Immunity 4 ff accination Declination <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 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 <br />o the best of m--�y�7���k-{�npp��wledge <br />and <br />and <br />belief the statements made <br />Signature: <br />�(.GL�Q_ / <br />Date: <br />/%L/l� <br />Print Name: <br />/J 17 <br />nn) <br />Title: <br />:in <br />are true <br />and <br />correct. <br />b <br />/2 Z <br />FILE USE ONLY 1' <br />(PE): 4110 Fees: t-173 Authorized by (REHS): Lry �D Date Entered: 6IZZrZt <br />