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� ��� ���� ��� <br /> .&��������0����� Environmental Health Department <br /> ' �~o�U�U�K�� ��� ������U������ <br /> **v�'nwnmvoo*po���.�� x ^°xv�/��u~��xnou�o� o <br /> Mobile Food Facility # Caterer <br /> {omP/ntnuoctionoIond2. /fynuronrn/nisuag/it/orotadvutsideof San Joaquin County also complete section % <br /> vvvnenupe/atnrmum <br /> Business a It g <br /> /. . hereby state that the above Information/ucurrent,true and cu'/oxttv <br /> the best 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 notjfy the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature 1� Date ' <br /> Check all appropriate services provided: <br /> WW' astewater disposal G-<compartment sink 2-Electrical hook-ups <br /> �r�Solid waste disposal 13 Food preparation U'Toilet and handwashing <br /> CKHot& Cold water for cleaning 011S�to_re refrigerated food ET_�Potable water <br /> 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'falls to com ly with the conditions Of *this agreement, or if this agreement 'is mod)fied or cancelled. *he <br /> Dat 2� <br /> The commissary islocated in County. The above food facility meets the <br /> commissary requirements inCe|ilunnioHealth & Safety 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 Date <br /> 18G8EHoze!1uoAvsnvoIStook1on. Ce|ifnrnis35Z05 | T20946D'542O1F2O9464-013O1vaeAksigov.org/ehd <br />