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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />t 1868 East Hazelton Avenue, Stockton, CA 95205-6232`" <br />ti Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd 41, '' Pp 01 <br />Application for Registration to Perform%��1� <br />Tattooing, Body Piercing, or Permanent Cosmetics <br />Pursuant to California Health and Safety Code, Chapter 7, Section 119300 <br />Name: <br />Phone Number: <br />Last First Middle Initial <br />Day Phone <br />Evening Phone <br />Business Name (if operating in additional facilities within this county, <br />please list name and addresses on back): <br />""d, e-- c o <br />B•�uOs/inessAddres/s: <br />�/) <br />Street Number city <br />State <br />Zi <br />Mailing Address: <br />U ' j 1-4, <br />�� o <br />Street N umber city <br />State <br />Zi <br />Please indicate the services that you will be providing: <br />�f 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 />N m lease Print Name) <br />LZ <br />Signature D to <br />EH 41-01 APP FOR REGISTRATION FOR TATTOOING <br />10/11/07 <br />