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AIRO SAN JOAQUIN COUNTY <br />NmENTAL HEALTH DEPAR T <br />Wit <br />.4- <br />A 304 East Weber Avenue, 3Td Floor, Stockton, CA 95202-2708 RECOVED <br />0 < <br />L2 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web. www.sjgov.org/ehd <br />DEC 1 5 t06 <br />Application for Registration to Perform ENVIRONNIENT HEALTH <br />Tattooing, Body Piercing, or Permanent Cosmetics P E P, 'MIT/SERIVIGES <br />Pursuant to California Health and Safety Code, Chapter 7, Section H 93 00 <br />Name: Phone Number: <br />goo)E-ES 5ZE167J i 5:3e - 7e2-0 3 <br />Lag First Nfime Initial D* Phone Evening Phone <br />Business Name (if operating in additional facilities widiin this county, please list name and addresses on back): <br />"RI) 7-4 77-6D/'Q- <br />Business Address: <br />2C) 0/ 0 Ck -57-, 953 7�- <br />Sued Number city Stec Z!2 <br />Mailing Address: <br />Sweet 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 />F-1 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 />F-1 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 />ase Pri N <br />=Name (Please Tint <br />t7 0( <br />Signature Oate <br />/ <br />EHD 41-01 <br />12/9//03 <br />