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0�wusay 4P SAN 1 <br /> N COUNTY J0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> . 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ` <br /> Telephone:(209)468-3420 Fax. (209) -01 e : .sjgov.org/ehd <br /> ��1FC3R <br /> Application i <br /> Tattooing, iriCosmetics <br /> Pursuant to CaMmia Health and Safety Code, Chapter 7, Section 119300 <br /> G\ C�c 0 // <br /> Name: Phone Number: <br /> C ASC1 L IS C F s�v 3 L-( -zs 0(� <br /> Last First Middle initial Da Phone Evening Phone <br /> Business Name(if operating in additional facilities within this county,please list name and addresses on back): <br /> se GVH � sick Tn i- ho <br /> Business Add <br /> 62 (� - � � CIT 3- <br /> Street Number state Zi <br /> Mailing Address- <br /> 1-0 <br /> ►'tet_ CA 6- C� <br /> Street Number C' _Swe__ 2i <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 includesu i Effited to: <br /> • Eyeliner <br /> • Lip color U(" I 0 ,1 2012. <br /> • Camouflage <br /> • Stencil designs ENVIRONMENTAL HEALTH <br /> • Free hand designs PE IP ERVI 3 <br /> [3 Body Piercing-The creation of an opening in the human body for the purpose of inserting <br /> jewelry or other decoration, This includes, but is not limited to, piercing of an ear, lip, tongue, nose, <br /> or 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 <br /> 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 <br /> agree to conform to all conditions, orders, and directions issued pursuant to the California Health and <br /> Safety Code and all applicable county and city ordinances. <br /> Name (Please PrintName) <br /> ( OISL <br /> Signature Date <br /> EHD 4"1 APP FOR REGISTRATION FOR TATTOOING <br /> 10/11/07 <br />