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SAN J Q A Q U I N Environmental Health ®epairlc€ ierr <br /> —COUNTY--- <br /> COMMISSARY <br /> OUNTY—._COMMISSARY REEi U AIi <br /> Mobile Food Facili)< <> Caterer <br /> Complete sections 1 and 2. If your commissary is located outside o;San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT c� <br /> Business Name Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address 's <br /> Ciiyv�lzlklo'A Statej�f Zip r�� Bus. Ph, 7r7I'Alt. Ph. <br /> 1,k_FAc �) k),e d'iaL) hereby state that the above information is current,true and correct to <br /> the b st of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit holder-must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penal ies. / <br /> Signature Date Z/2-0 12a Zb <br /> 2. To be completed by QOMMISSARY O NER/OPERATOR <br /> I (% <br /> Commissary Name C{ 1 FA# <br /> Address u) . ' L Bus. Phone i )q- S '�7U <br /> City c 4L. Zip 0 5 Oivne 10perator , C' � <br /> Check all appropriate services provided: <br /> X Wastewater disposal X 3-compartment sink Electrical hoof:-ups <br /> gg Solid waste disposal Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaning Store refrigerated food Potable water <br /> dry food/sup lies X Overnight parking Vehicle wash <br /> ����Y/}ll�a��, hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,,dfid meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to-comply with the, 6nditions of ra agreement, or if this agreement is modified or cancelled, the <br /> commissary wt1Er shalj.notify -Ef ID imnie aely. �/' <br /> �'w" <br /> Signature ��' �� r Date 6A .� <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin moo. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> RENS Signature Date <br /> 1868 E. Hazelton Avenue l Stockton, Cafff®rnia 95205 1 7 209 468-3420 1 i 2034.64-0138 1 wvrw.sjgov_o4ehd <br />