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San Joaquin County 1868 east Hazelton Avenue <br />(. Environmental Health Department Stockton, CA 95205 <br />Tel: (209) 468-3420 <br />` <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 />Feeeeel-Fattoolng M Body Piercing r7mechanical Stud and Clasp Ear Piercing <br />Branding Mermanent Cosmetics <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES: Check all that apply. <br />1F"JAnnual Body Art Practitioner Registration 3r7Mechanical Stud and Clasp Ear Piercing Notification <br />252jAnnual Body Art Facility Permit <br />III. APPLICANT INFORMA <br />T/IQ' N/` <br />NAME: I d-yj 10 P'" C_ `eWL{'.y Phone: (e?oe <br />IV <br /> ,' <br />BODY ART PRACTITIONER ONLY <br />Date of Birth: <br />Identification Type: FmDrivers License Feeeel0ther <br />Gender: M or MM (circle one) <br />Identification No.: <br />Facility where Body Art Services Will be Provided <br />Facility Name: <br />Owner: <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 by: <br />Hepatitis B Vaccination Status: Choose One and Submit Documentation <br />1r7Certification of Completed Vaccination 3MContraindicated for Medical Reasons <br />2[:]Laboratory Evidence of Immunity 4®Vaccination Declination <br />NESS NAME: <br />address: <br />Owner/ Contact: Phone/ Fax <br />The undersigned hereby applies for a eDdy 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 arL_jjj.QwLLes or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify that to the of my know) dge and belief the statements made beret n/Pretru and correct. <br />Signature: , - - Date: .G d�,� <br />Print Name: (,r> HC.0 $ Title: tJ�Vj <br />R OFFICE USE ONLY <br />Tram (PE): 4i ; () Fees: 8 ,:233 Authorized by (RENS): ,ZI N <br />n <br />fn.l Date Entered: <br />n <br />