Laserfiche WebLink
San Joaquin County <br /> q 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 9s2os <br /> P C Tel: (209)468-3420 <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 =Body Piercing =Mechanical Stud and Clasp Ear Piercing <br /> Branding ffxpermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES:Check all that apply. <br /> ittAnnual Body Art Practitioner Registration 3= <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> The undersigned hereby app es for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud and Ear Piercing Notifi tion and agrees to operate in accordance with all applicable state and local <br /> requirements governing sa,' o art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certifygthat to th/bes knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> FQR'OFFICE USE ONLY <br /> 3 <br /> program (PE) f 10 Fees: !1 02 Authorized b REHS <br /> Y( ): � Enterer � x� <br /> a <br /> f2 <br />