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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave • Stockton, CA 95205-6232 • Phone (209) 468-3420 <br /> Jasjit Kang, R.E.H.S., Director <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE - PE 4110 - BODY ART PRACTITIONER REGISTRATION <br /> Permit ] D # PT0024613 for Record ID # PRo540005 <br /> Valid From 7/1 /2022 To 6/30/2023 <br /> PERMIT TO OPERATE - PE 4120 - BODY ART FACILITY-SINGLE USE <br /> Permit ID # PT0028120 for Record ID # PRO546977 <br /> Valid From 7/1 /2022 To 6/30/2023 <br /> PERMITS TO OPERATE are NOT TRANSFERABLE <br /> and may be SUSPENDED or REVOKED for cause <br /> PERMIT(s) Valid only for: EDGINGTON , WILLIAM J <br /> DBA: PURE FORM GALLERY & TATTOO <br /> THIS FORM MUST BE DISPLAYED CONSPICUOUSLY ON THE PREMISES <br /> Regulated Facility: PURE FORM GALLERY & TATTOO (EDGINGTON,WILLIAM) Facility ID FA0022860 <br /> 213 W YOSEMITE AVE Account ID AR0041930 <br /> MANTECA CA 95336 issued 5110/2022 <br /> Billing Address: ATTN : EDGINGTON , WILLIAM J <br /> PURE FORM GALLERY & TATTOO <br /> 213 W YOSEMITE AVE <br /> MANTECA CA 95336 <br /> 7027 rpt End of Report <br />