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SAN JOAQUIN COUNTY <br /> E ONMENTAL HEALTH DEPART <br /> r■ _ AP <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax.(209)464-0138 Web:www.sjgov.org/ehd <br /> Application for Registration to Perform <br /> Tattooing, Body Piercing, or Permanent Cosmetics c�c�,�Ty <br /> Pursuant to California Health and Safety Code, Chapter 7,Section 119300 <br /> Name: Phone Number: <br /> �Q ZlY11 2A r2 939 640/ 2v9 %9 p0 <br /> Last First Middle Initial Day Phone Evening Phone <br /> Business Name(if operating in additional facilities within this county,please list name and addresses on back): <br /> L-i-V_7 N i� =/ K <br /> Business Address: <br /> I qZ SiiT�_- A LAeCH 2��� //L&Cy G4 175soo t <br /> Street Number city State Zi <br /> Mailing Address: <br /> Street Number <br /> City State Zi <br /> Please indicate the 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. This includes, but is not limited to: <br /> • Eyeliner <br /> • Lip color <br /> • Camouflage <br /> • Stencil designs <br /> • Free hand designs <br /> Body Piercing—The creation of an opening in the human body for the purpose of inserting 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 /> [� 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 that 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 /> 1ZA2F/2 �6R.�K 3/Y�1 <br /> Name(Please Print Name) <br /> Cq /p} <br /> Signature Date <br /> EHD 41-01 WEB <br /> 8/8/2007 <br />