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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 ID# PT0024613 for Record ID# PR0540005 <br /> Valid From 7/1/2023 To 6/30/2024 <br /> PERMIT TO OPERATE - PE 4120-BODY ART FACILITY-SINGLE USE <br /> Permit ID# PT0028120 for Record ID# PR0546977 <br /> Valid From 7/1/2023 To 6/30/2024 <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 5/25/2023 <br /> Billing Address: ATTN : EDGINGTON, WILLIAM J <br /> PURE FORM GALLERY&TATTOO <br /> 213 W YOSEMITE AVE <br /> MANTECA CA 95336 <br /> End of Report <br /> 7027.rpt <br />