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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 Body Piercing MMechanical Stud and Clasp Ear Piercing <br />L_jBranding OPermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1®Annual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br />2[::]Annual Body Art Facility Permit <br />III <br />, <br />Date of Birth: Z_ r l <br />Gender: or M (circle one) <br />Identification Type: Drivers License Other <br /> <br /> <br />Facility where Body Art Services Will be Provided <br />Facility Name: F b <br />Owner: (,h,- Pfft�(21n <br />Address: �' <br />Evidence of Six months of Related Experience <br />Facility Name: <br />Owner: <br />Address: <br />Service You Provided: <br />Supervisor Name and Contact Information: <br />Bloodborne Pathogen Training: Submit Certificate <br />Date Completed: Training Provided <br />by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1MCertification of Completed Vaccination <br />3MContraindicated for Medical Reasons <br />2MLaboratory Evidence of Immunity <br />4=Vaccination Declination <br />IV. FACILITY LOCATION (S): (Attach additional sheets as necessary) <br />Location address: <br />Suite: <br />v -1 <br />Owner/ Contact: 1-4 P IA ,_N i'... Y) Phone/ Fax: / (�'I 1 & 1 10t o <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 governi g safe bo a practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify th the edge and belief the statements ma a herein are true and correct. <br />Signature: Date: "" J <br />Print Name: c (,i -e Title: <br />