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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 # PRO540005 <br /> Valid From 6/7/2021 To 6/30/2022 <br /> PERMIT TO OPERATE - PE 4120 - BODY ART FACILITY-SINGLE USE <br /> Permit ID # PT0028120 for Record ID # PRO546977 <br /> Valid From 6/712021 To 6/3012022 <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 /> 213WYOSEMITEAVE Account ID AR0041930 <br /> MANTECA CA 95336 Issued 611012021 <br /> Billing Address: ATTN : EDGINGTON , WILLIAM J <br /> PURE FORM GALLERY & TATTOO <br /> 213 W YOSEMITEAVE <br /> MANTECA CA 95336 <br /> 7027.rpt End of Report <br />