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c 1868 East Hazelton Avenue <br /> z <br /> San Joaquin County <br /> Environmental east Department Stockton,CA 95205 <br /> 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 /> attooing ElBody Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRE!�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 /> Z Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATION: <br /> NAME: Phone: 512-7 <br /> HOME ADDRESS: ® Email: �k <br /> City: T, P State Zip County• GP <br /> BODY ART PRACTITIONER ONLY <br /> Date of Birth: �j Gender: F or (circle one) <br /> Identification Type: Drivers License Other Identification No.: <br /> Facility where Body Art Services Will be Provided <br /> Facility Name: C Owner: <br /> Address: ' <br /> Evidence of Six-months of Related Experience r <br /> Facility Name: Owner: <br /> Address: ag <br /> Service You Provided: <br /> Supervisor Name and Contact Information: <br /> Bloodborne Pathoge T 'ng: Submit Certificate <br /> Date Completed:N CA M Training Provided b <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1 Certification of Completed Vaccination 3 Contraindicated for Medical Reasons <br /> Z Laboratory Evidence of Immunity 4 accination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: 1 c <br /> Location address: Suite: <br /> City: State: Zi Count <br /> Owner/ Contact: Phone/ Fax: <br /> 2. BUSINESS NAME: r 1 <br /> r----- <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 certifAtpat to the bes of my kno edge and belief the statements made herein are true and correct. <br /> Signature: _ Date: /'214 <br /> Print Name: Title: r <br /> FOR OFFICE USE ONLY <br /> Program (PE): Fees: Authorized by (RENS): Date Entered: <br /> ---If2 <br />