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San Joaquin County • 1868 East Hazelton Avenue CA Environmental Health Department artment Stockton, 463220 Tel: (209) 468--3420 Fax: (209) 464-0138 BODY ART FACILITY AND PRACTITIONER REGISTRATION/ MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) �ttooing aBody Piercing Mmechanical Stud and Clasp Ear Piercing Branding aPermanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. i[�@Annual Body Art Practitioner Registration 3QMechanical Stud and Clasp Ear Piercing Notification 2QAnnual Body Art Facility Permit III. APPLICANT INFORMATION: NAME: �G� }� y .S.�,uGA of , [`D r1. Phone: 70 l - 70 y - 42679 l et". -X Date of Birth: Gender: M or (circle one) Identification Type: Drivers License Mother Identification No.: Facility where Body Art Services Will be Provided FacilityName: Ti Owner: Address: ►'l ti% Evidence of Six -months of Related Experience Facility Name: Owner: Address: Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Completed: 5 9 V1 " I S Training Provided by: & -G �� Hepatitis B Vaccination Status: Choose One and Submit Documentation 1MCertification of Completed Vaccination 3 MContra Indicated for Medical Reasons 2[DLaboratory Evidence of Immunity 4'U.SiLarcination Declination IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) 1. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: 2. BUSINESS NAME: Location address: Suite: City: State: Zip: County: Owner/ Contact: Phone/ Fax: The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. I hereby certify that to the best of my knowledge and belief the statements made herein are true and correct. Signature: Date: Print Name: Title: