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• <br />SAN JOAQUIN COUNTY <br />of <br />ENVIRONMENTAL HEALTH DEPARTMENT <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 <br />Pursuant to California Health and Safety Code, Chapter 7, Section 119300 <br />Name: <br />e re /v\ v� <br />Phone Number: <br />�? .5�s = C��� <br />Last First r Middle Initial <br />Day Phone Evening Phone <br />Business Name (if operating in additional facilities within this county, please list name and addresses on back): <br />t/e /V1Goi y ..%�.. <br />Business Address: <br />2_30& <br />Street Number <br />State Zi <br />Mailing Address: <br />l� , � G r <br />_ <br />Street Number it <br />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 <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 />(Please Print Name) <br />ignature Date <br />EHD 41-01 APP FOR REGISTRATION FOR TATTOOING <br />10/11/07 <br />