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ISA N .1 OAO U I N Environmental Health Department <br /> —COUNTY— <br /> G <br /> 0 <br /> COMMIS,R�' F-,��'V z�,_ N:�,E FEE M E IR",7 <br /> Mobile Food Facility Caterer <br /> Complete sections I and 2. If your commissary is located outside al'San Joaquin Coun4"also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name: —Lic. Plated <br /> Owner/OperatorName <br /> Business Mailing Address <br /> C i StateOPP Zip 6/'5_JO Bus. Ph,,-)G 2Z- Alt. Ph. <br /> hereby statethatthe above information is current,true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California., Health (or. <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,the permit holder roust nofify the EHD. Failure to notify this office may result in pert-pit <br /> revocation a d penalties. <br /> Signature r" P(OA-d' —Date <br /> 12. Tocompleted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name x& (t)y :�cj'u_ z _FA# <br /> Bus. Phone <br /> Address-5� MmK:i" <br /> Cil 7-ip Gwnedoperator �kl; <br /> Check, all appropriate services provided: <br /> Wastewater disposal 'A 3-comparunnent sink Electrical hook-ups <br /> i�- Solid waste disposal f Food preparation Toilet and handvvashing <br /> X Hot& Cold water for cleaning Store refri%erated food Potable water <br /> S;Wue dry food//supplies! <br /> ood/supplies Overnight parking Vehicle wash <br /> (_ A_jU111&1_1'E -7— _, hereby State that the information I have provided is curreni,true and <br /> correct to the best of my knowledge,and Jets the California Health&Safety Code requirements. If the food facility <br /> amply with the con .r186sc of this agreement, or if this agreement is modified or cancelled, the <br /> operator fails�P� <br /> commissa �,611nn,qr shall notify thb-I]J41)immediately. <br /> Date <br /> Signature <br /> ?7- 61 <br /> o To ire completed by the 'R4V Jun diction outside of San Joaqui <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 COMMiSS2ry. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1366 LE. Hazelton Avenue Calif <br /> Or:jia 9!-:205 � 7 20-9a 468-3420 1 F 209 464-0138 1 twiffy.sigair.org/ehd <br />