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San Joaquin County 1868 East Hazelton Avenue Stockton, CA 95205 Environmental Health Department 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) Tattooing Body Piercing MMechanlcal Stud and Clasp Ear Piercing Branding r7permanent Cosmetics II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES; Check all that apply. Gender:75F or M circle one) Identification Type: Drivers License MOther 17JAnnual Facility whet ody Art Sam s Will be Provided Body Art Practitioner Registration 3QMechanical Owner: Stud and Clasp Ear Piercing Notification II: Body Art Facility Permit Date of Birth: Gender:75F or M circle one) Identification Type: Drivers License MOther Identification No.: Facility whet ody Art Sam s Will be Provided , FacilityName: Owner: Address: ca v` Evidence of $i,X mionths Related Experie ce Facility Name:t�lk \� Owner: Addres 4V 'tV, '� Service You Provided: Supervisor Name and Contact Information: Bloodborne Pathogen Training: Submit Certificate Date Competed: Training Provided by: Hepatitis B Vaccination Status: Choose One and Submit Documentation 1MCertification of Completed Vaccination 3MContra indicated for Medical Reasons 2[=Laboratory Evidence of Immunity 4[=Vaccination Declination IV 2. BUSINESS NAME: City: State; Zip: County: 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 ening safe body art ractices or practices governing mechanical stud and clasp ear piercing. I hereby ce ify t t he has ,of y�know edg and belief the statements made herein are true and correct. Signature: / Date: Print Name: Title: FOR OFFICE USE ONLY (PE): Fees; Authorized by (RENS): Date Entered: