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/qu fly, SAN.TOAQUIN COUNTY <br /> �O. QOG\ <br /> Q 2;, E NMENTAL HEALTH DEPART <br /> coo ` 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 Eve(209)468-3420•Fax:(209)464-0138 • Web:www.co.sanjoaquin.ca.us/ehd � <br /> .9��QRSa <br /> ED <br /> Application for Registration to Perform EN JUN 2 92010 <br /> Tattooing, Body Piercing, or Permanent Cosmetics �,�lRDIVAfE;yTt� T <br /> Pursuant to California Health and Safety Code, Chapter 7, Section 119300 , <br /> '7eCS <br /> Name: Phone Number: <br /> ` 09V 7 1 - Ob a -y/y <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 /> Lo f <br /> Busin ss Address: <br /> JR 55 44 iq r boU r r cL-H n clS a l <br /> street Number City State Zi <br /> Mailing Address: <br /> LI Ar of n a <br /> Street Number —city State Zi <br /> Please indicate the services that you will be providing: <br /> V5-- 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 /> Name (Please Print Name) <br /> Signature Date <br /> EHD 41-02-001 <br /> 12/9//03 <br />