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�jzi" <br /> (209)468-3420-Fax.(209)464-0138- Web: .co.sanjoaq ' .ca.us/ena <br /> iti for Registration , <br /> Tattooing, BodyL <br /> Piercing, r Permanent t et1Cs LL�' <br /> Pursuant to California Health and Safety Code, Chapter 7,Section 119300 J <br /> Name: Phone Number: <br /> LA —1e5Q— <br /> Last 1 <br /> F Muldk W-alWfial my Phow EM�ng Phone <br /> Business N (if operating in itional talbilities within this county,please list name and addresses on back): <br /> USC - <br /> BusinessQ <br /> dress: <br /> NmW= Pity stale <br /> t <br /> Mailing Address: <br /> Q190-7 - <br /> sacec N SM <br /> Please indicate a services that you will be providing: <br /> Tattooing—Inserting pigment under the surface of the skin by pricking with a needle or otherwise, <br /> to produce an indelible mark or figure visible through the skin. includes,but is not limited to: <br /> • Eyeliner <br /> • C p oufla ga olor JUN 1 2011 <br /> - • <br /> • Stencil designs EWRONMENTAL HEALTH <br /> • Free hand designs PERMMSERVICES <br /> Body Piercing—The creation of an opening in the human body for the purpose of insetting jewelry <br /> or other decoration. This includes,but is not limited to,piercing of an ear,lip,tongue,nose,or <br /> eyebrow. Body piercing does not;for the purpose of this definition,include piercing the leading <br /> edge or earlobe of the ear with a sterile,disposable,single-use stud or solid needle that is applied <br /> using mechanical device to force the needle or stud through the ear. <br /> El Permanent Cosmetics—The application of pigment to or under the skin of a human being for the <br /> purpose of permanently changing the color or other appearance of the skin. This includes,but is not <br /> limited to,permanent eyeliner,eye shadow,or lip color. <br /> I declare that to the best of my knowledge the information at I have provided is true and accurate. I also <br /> agree to conform to all conditions,orders, and directions issued pursuant to the California Health and Safety <br /> Code and all applicable county and city ordinances. <br /> Name(Please Prin acne) <br /> 1 <br /> Sij6ature Date <br /> EH(D 41-02-001 <br /> 12/9//03 <br />