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San Joaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton,CA 95205 <br /> 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 /> L PROCEDURES TO BE PERFORMED:Check all that apply(see back for definitions) <br /> '®Tattooing moody Piercing Mechanical Stud and Clasp Ear Piercing <br /> Brandi ng Permanent Cosmetics <br /> 13. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notificati <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> ies 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 /> mcuirements governing/safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> hereby certify th 3 to/th/eb�,S 0 Y owledge and belief the statements made herein are true and correct. <br /> igneture: �I�,, I Date: <br /> F rint Name: Title: <br /> FC,R OFFICE USE ONLY <br /> Program (PE): 1411) Fees: Authorized by(REHS): G90 Date Entered: <br /> f2 <br />