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uww e. <br /> r S1 7- <br /> AN QU"TY E'1GVIR NMENTAL HEALTE"�fIRTMENT i <br /> 1868 E.Hazelton Ave. •-Stockton,CA 95205-6232 •.hone(209)468-3420 <br /> • <br /> Donna Heran,R.i".-Director <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE - 4110-BODY ART PRACTITIONER REGISTRATION <br /> Permit ID#PT0023002 for Record ID#PR0537483 <br /> Valid From 7/1/2013 To 6/30/2014 <br /> * * * D U P L I C A T E <br /> PERMITS TO OPERATE are NOT TRANSFERABLE <br /> and may be SUSPENDED or REVOKED for cause. <br /> PERMIT(s)Valid only for: AZEVEDO,JEREMY D <br /> THIS FORM MUST BE DISPLAYED CONSPICUOUSLY ON THE PREMISES <br /> Regulated Facility: BLACK ROSE TATTOO (AZEVEDO,JEREMY[ Facility ID FA0021565 <br /> Account ID AR0039037 <br /> 237 E MINER Issued 4/1/2014 <br /> STOCKTON CA 95206 <br /> Billing Address: ATTN : AZEVEDO, JEREMY D <br /> BLACK ROSE TATTOO (AZEVEDO, JEREMY D) <br /> 1834 LUCERNE AVE <br /> STOCKTON CA 95203 <br />