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u San Joaquin County is 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton -3220 <br /> p Tei: (209))4 4668-3420 <br /> oti` 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 /> ®BrandingLVLPermanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> i Annual Body Art Practitioner Registration 3®Mechanical Stud and Clasp Ear Piercing Notification <br /> 2®Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: jai Phone: <br /> <br /> <br /> 1,0111 WIN-1 0 m 1-10WACTO <br /> Date of Birth: t�®' Gender: F or MM (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: e- _ d J Owner: <br /> Address: \/V <br /> Evidence of Six-months of Related Experience <br /> Facility Name: Owner: <br /> Address: <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathog n Training: Submit Certificate - <br /> Date Completed: Training Provided by: 01 ci -jduns <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1®Certification of Completed Vaccination 3®Contraindicated for Medical Reasons <br /> 2®Laboratory Evidence of Immunity 4 Vaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: Uxk4c w4l� 4 cac— <br /> Location address: Suite: <br /> City: State: Zip: ,5DCounty: tYll <br /> Owner/Contact: s e, Leuv& Phone Fax: v -3 <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 Mb&my knowled belief the statements m de h rein are true and correct. <br /> Signature: Date: <br /> Print Name: Title: <br /> / / � r x� y� y vim % 2 <br />