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t►'�Y <br />Body Art Inspection Report <br />County of San Joaquin County, Environmental Health Department <br />' < <br />1868 E. Hazelton Ave., Stockton CA 95205 <br />(209) 468-3420 www.siaov.om/ehd <br />Date (MM/DD/YY) <br />Permit Number 90, ��toS H3 <br />Permit Type 1'll Z <br />Facility Name Address <br />Foriw, n ToAwa 134o A ff-j --U <br />City <br />Lo"Id <br />Zip Cod <br />Q521� <br />CT <br />Sun <br />Permit/Registration Holder Name <br />�.. ,,. , _ v ... <br />Permit Exp. Date Total Time Inspection Type g <br />A r� �f1s.!•v`i'ti�ts'1 <br />St= VA 1f) A DORRE( gt%Ti0 Ste, 4. '..3 . ..... . N . n. <br />11) m(4 <br />Jtv <br />Z4 <br />OV -Cl M "N <br />i rl ' <br />L1 <br />3 <br />P- G ii <br />0VU()f,-- <br />S <br />LOrM Ott-, k <br />(c ' <br />c <br />(c <br />0 <br />41113— <br />f C ere <br />.t 1l?n <br />WA <br />61 <br />Al <br />L4 jy) ,' <br />brh M' <br />Z, <br />S km S <br />' L <br />s <br />s .rte <br />-r <br />A <br />fe) <br />t'& <br />i 11 <br />Received b (Print): ' Received b Si nature Phone: 7-6;5-4101— 0 <br />Specialist (Print): G$Lt)D Specialist (Signature): Phone: <br />6m) u r <br />F]This report is an Official Notice of Violation. Corrections must be completed in the time specified. <br />A reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date (on or about) <br />Pagel of _ <br />