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San Joaquin County 1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Environmental Health Department Tel: (209) 468-3420 <br />�.�aas• 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 IDBody Piercing MMechanical Stud and Clasp Ear Piercing <br />Branding EDPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1QAnnual Body Art Practitioner Registration 3r--JMechanical Stud and Clasp Ear Piercing Notification <br />2MAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />NAME: <br />\ (� I f C� <br />NAME: �CCLC�`EL`��2`(� <br /> <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: �U U U <br />Gender: F or M (circle one) <br />Identification Type: MDrivers License MOther <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: G\UC G:`` O <br />Owner: <br />Address: 25 t Si' \c� C <br />'Q�j�L�U <br />Evidence of Six -months of Related Experience <br />Facility Name: �0. C <br />Owner: GL <br />n4- <br />Address: (r-��5 �S�rQ S� \t) L `l <br />`U <br />Service You Provided: 10.6ue, ` <br />Name and Contact Information: a o <br />/ <br />`Q 0 U O' <br />.Supervisor <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 3MContraindicated for Medical Reasons <br />2[::]Laboratory Evidence of Immunity 4[:DVaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />pp i I <br />Owner/ Contact: 1�Oc" Phone/ Fax: <br />2. BUSINESS NAME: <br />Location addres<_ <br />City: <br />Owner/ Contact: <br />State: <br />Fax: <br />Suite: <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 t he best of my knowledge and belief the statements made herein are true and correct. <br />Signature: Date: -1'(a' <br />Print Name: C;,�,#- t Title: i:5 QCc i ore f <br />FOR OFFICE USE ONLY <br />Program (PE): -A./// Fees: $11,2 Authorized by (RENS): Grl Date Entered: <br />