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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue <br />Stockton, CA 95205 <br />Tel: (209) 468-3420 <br />Fax: 1209) 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 MPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1�Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification <br />20Annual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: Gender: F or M (circle one) <br />Identification Type: rivers License Other Identification No.: CA B <br />Facility where Body Art Services Will be Provided <br />Facilit Name: Y Owner: J <br />Address: 1 <br />Evidence of Six -months of Related Experience <br />Facility Name: Lee_ Owner: <br />Address: C <br />Service You Provided. <br />ISu ervisor Name and Contact Information: , <br />Bloodbor ne Pathogen Training: Submit Certificate <br />Date Completed: 210 Ap 1,j)OT'rainin Provided by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1®Certification of Completed Vaccination 3®Contraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity 4[rilvaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />I. BUSINESS NAME: <br />Location address: <br />Suite: <br />City: State: Zip <br />County <br />Owner/ Contact: Phone/ Fax: <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 the est of my knowledge and belief the statements mad here'n are true and correct. <br />Signature: Date: '� . �l� j 7 <br />Print Name: - Title: <br />FOP. OFFrICE USE ONLY <br />Program (PE): Fees: Authorized by (REHS): Date Entered: <br />if� <br />