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`"o� SAN JOAQUIN COUNTY <br /> z <br /> ENOONMENTAL HEALTH DEPART <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 952b2-2708 <br /> T (209)468-3420•Fax:(209)464-0138• Web:www.co.san-joaquin.ca.us/ehd <br /> CEI <br /> VE <br /> Application for Registration to Perform `lN 0 2012 ter/ <br /> /A <br /> Tattooing, Body Piercing, or Permanent Cosmetics <br /> Pursuant to California Health and Safety Code, Chapter 7, Section 119300 �V IR NY"N7, <br /> MIT/SE Eq�Tjy <br /> Name: Phone Number: <br /> b 3` 333 -r3014- <br /> Last First Middle Initial Day Phone Evening Phone <br /> Business Name(if operating in additional facilities within this county,please list nameIeaand addresses on back): <br /> ft <br /> Business Address: <br /> Street Number Ci Stazip <br /> Mailing Address: <br /> c b ao NQ Ca ' cam- <br /> Street Nmnber city State Z <br /> Please indicate the services that you will be providing: <br /> � <br /> , IT � 901?-15?� <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 /> Name(Please Print Name) <br /> Signa a Date <br /> EHD 41-02-001 <br /> 12/9//03 <br />