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San Joaquin County 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department 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 MBody Piercing Mmechanical Stud and Clasp Ear Piercing <br /> Branding jo Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> kEZI,Qnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2C254nnual Body Art Facility Permit <br /> III.APPLICANT INFORMATIO (� _G <br /> NAME: U" I ll \�1/ Phone: cl� <br /> <br /> <br /> Date of Birth: W- 0 Gender: F/or M (circle one) <br /> Identification Type: Drivers License MOther Identification No.: <br /> Facility where Bod Art Services Will be Provided <br /> Facility Name: 0111 r Owner: <br /> Address: ;?_J CL CA 1. Pfu C <br /> Evidence of Six-months of Related Experiente <br /> Facility Name: S V 1; 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 /> Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> Laboratory Evidence of Immunity 4[=]Vaccination Declination <br /> IV. FACILITY LOCATION (S): ` <br /> (Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: 0 V f G i1 Sq ,, <br /> _Location address: ���v �C' U -c' Suite: cC <br /> City: Q State: Zip: County:: ,Gcvi <br /> Owner/Contact: �,i \Ld Phone/ Fax: ©� l i� k (, <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <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 to tl best of y knowledge and belief the statements made herein are true and correct. <br /> Signature: Date: ' a Ci <br /> Print Name: Title: 0�AJ+1 d n <br /> V, f2 <br /> r/ 6G�1I ' <br />