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`'t"`. <br />SAN JOAQUIN COUNTY <br />EN#ZENTAL HEALTH DEPARTM <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />(209) 468-3420 • Fax. (209) 464-0138 • Web: www.co.san-joaquin.ca.us/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: Phone Number: <br />Last First I 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 />Business Address: <br />Street Number city State Zi <br />Mailing Address: <br />57 -OG k- T-&,) CIA <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, 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 />1> �xse- t Ia vcrr � ,f <br />ame (Please rint me) <br />Signature Dafe <br />EHD 41-02-001 <br />12/9//03 <br />