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'. <br /> � \. �AN. OADQIN Environmental Health Department <br /> ---COUNTY— <br /> COMMISSARY ������K�����7� <br /> »°x��/o��~�~x�o�~xmo <br /> Mobile Food FaSilitV + Caterer <br /> Complete sections / and 2 If your commissaty is located outside of San Joaquin County also complete section 3. <br /> 1-. To.be.completed,by APPLICANT <br /> Business Name J 'S 140+- DIdAcklil4si 'Do* Lic. Plate# <br /> Business Mailing Address 105 'SC-QUOIA C+. 95_Z05' <br /> City STDCV-MN State <br /> iAA0 tkCAWAti0fthereby state that theabove 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 & <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 ande |ti <br /> F2—To bi� completed by_'COM058ARY OWN EFC1,00 <br /> A B <br /> Ci i Owner/Operatu <br /> Check all appropriate services provided: <br /> Wastewater disposal X3-cornpurtnoentsink 13Electrical hook-ups <br /> Solid waste disposal 9 Food preparation 5< Toilet and handwaohing <br /> Hot & Cold water for cleaning XStore refrigerated food Potable water <br /> St-pre dry food/s.Lmplies E3 Overnight parking Vehicle wash <br /> |' . hereby state that the information ( 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 tocomply with the ; nd't'ons ofthi agreement, or ifthis agreement ismodified u/ cancelled, the <br /> commissary <br /> Signature —Date-4 <br /> _ <br /> Td be c6rripleted by We ENVHEALTH <br /> The commissary irlocated 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 /> REHS Signature Date <br /> 188DE. Hazelton Avenue ) Stockton, California 952U51T208450'J4201F209454'81501w^w*,sj0ovorg/ehd <br />