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d <br /> RECEIVED <br /> C2��N <br /> SAN JOAQUIN COUNTY j i°a 2 7 2012 <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1 600 East Main Street, Stockton, CA 95202-3029 <br /> ENVIRONMENTAL HEALTH <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehdPERMIT/SERVICES <br /> Application for Registration to Perform <br /> Tattooing, Body Piercing, or Permanent Cosmetics <br /> Pursuant to Califkmia Health and Safety Code, Chapter 7,Section 119300 <br /> Name: Phone Number: <br /> 9- XYZ - D Z- <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 /> i c— <br /> Business Address: <br /> 506 6. C, O <br /> Street Number city State Zi <br /> Mailing Address• <br /> 5J 6, {d P.1�1�1j fi/aw <br /> Street Number CRY 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 /> fiG <br /> Name Please Print Name) <br /> gnature Date <br /> EHD 41-01 APP FOR REGISTRATION FOR TATTOOING <br /> 10/11/07 <br />