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It <br /> PUBLIC HEALTH SER 199 -10 <br /> SAN JOAQUIN COUNTY §5 9 4r <br /> ENVIRONMENTAL HEALTH DIVISION AL i�E�i. <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor - Stockton, CA 95202 6Oil <br /> 209/468-3420 <br /> APPLICATION FOR REGISTRATION TO PERFORM <br /> TATTOOING, BODY PIERCING, OR PERMANENT COSMETICS <br /> Pursuant to California Health and Safety Code,Chapter 7,Section 119300 <br /> Name lone Numbers <br /> q(A t,-) � c:>" C— - - (2 Lis's-]sb,?q <br /> Last First Middle Initial Day F,eninp <br /> Business Name(if operating in additional facilities within this county please list name and addresses on back) <br /> Business Address' <br /> q i -7 C T (Z A L <br /> City,State,Zip <br /> C-A C7 6J-r(?-FLl_ v ' R IlR L <br /> Niiiiing Address <br /> VIA <br /> City,State,Zip <br /> Please indicate the services that you will be providing: <br /> Tattooin - Inserting pigment under the surface of the skin by pricking with a needle or <br /> Not ierwise, to permanently change the color or appearance of the skin or to produce all indelible <br /> mark or figure visible through the skin. This includes but is not limited to, eyeliner, lip color, <br /> camouflage, stencil designs and free hand designs. <br /> [] Body Piercing - The creation of an opening in the human body for the purpose of' <br /> inserting jewelry or other decoration. This includes but is not limited to, piercing of an ear. lip, <br /> tongue, nose or eyebrow. Body piercing does not, for the purpose of this definition, include <br /> piercing the leading edge or earlobe of the ear with a sterile, disposable, single-use stud or solid <br /> needle that is applied using a mechanical device to force the needle or stud through the ear. <br /> FJ Ilermanerit Cosmetics - The application of pigment to or under the skin of 1 Miran <br /> being [or the purpose of permanently changing the color or other appearance of the skin. 'I'his <br /> includes, but is not limited to, permanent eyeliner, eye shadow, or lip color. <br /> I declare that to the best of my knowledge the information that I have provided is true and accurate. I also agree to <br /> conform to all conditions, orders aild directions, issued pursuant to the California Health and Safety Code. and all <br /> applicable County and City Ordinances. <br /> -�) ON (S-iAL ftlo D <br /> Name <br /> Sign <br /> ign e Date <br />