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SAN JOAQUIN COUNTY <br /> G?, <br /> EN&ONMENTAL HEALTH DEPART <br /> 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 <br /> o �¢ <br /> (209)468-3420•Fax:(209)464-0138 e Web:www.co.san-joaquin.ca.us/ehd <br /> �CrFotaea <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: Phone Number: <br /> TV1 (J 201 `F '? (z0 $3� t)W <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 /> N K LE floo /\P0 r t BCW <br /> Business Address: <br /> W. [Itk me C �p <br /> Street Number city State Zi <br /> Mailing Address: <br /> Uv C 1 sr Tkac C } <br /> Street Number city State zip <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,t or <br /> eyebrow. Body piercing does not, for the purpose of this definition, include pie 1 ❑❑ D <br /> edge or earlobe of the ear with a sterile, disposable, single-use stud or solid needle that is applied D <br /> using mechanical device to force the needle or stud through the ear. MAR 12 201 <br /> El's ViR <br /> ❑ Permanent Cosmetics—The application of pigment to or under the skin of a h latAi4ifILTH <br /> purpose of permanently changing the color or other appearance ofthe skin. This�md4WWVigav <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 /> / o OC) <br /> Name(Please Print Name) <br /> L& Vj-�Z ?c/o <br /> Signature Date <br /> EHD 41-02-001 <br /> 12/9//03 <br />