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v SAR1A0UN <br /> Environmental Health Department <br /> ~--[0UNTY-- <br /> G,00tnr5s grows ho/u <br /> ��o�U�U�K����� �^�����U����� <br /> ����nnnx�no����x~�xn` ox~x��o`�����o�x�~n� x <br /> Mobile Food Facility + Caterer <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business N <br /> Ci i Bus. Ph. Ph <br /> | hereby state that the above information iscurrent,true and correct to <br /> the best of my knowledge and agree'(o 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 /> revocat' d It <br /> Signature Date /—2 —767 <br /> Cit '546j<6n —zip (_26!'20 �� Owner/Operator '%bM_d_4 Cel; 5 <br /> Check all appropriate services provided: <br /> :�H=t .ld water for cleaning 14- Store-refrigerated food otab ater <br /> ta <br /> 1, sjj)j2C�6 hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails ply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> Signatu Date <br /> The commissary iolocated in County. The above food facility meets the <br /> commissary requirements inCalifornia Health & Gn{oty—Code The above checked services are available atthe <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Dat <br /> 1050E. Hazelton Avenue | Stockton, California 952051 T 209488'34201 F 209464'0158 |wx^mv.sjQov»rg/ohd <br />