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. <br /> unv^ronmentaUHeafth Department <br /> wQK` O& w8N <br /> � . '---C{)i] NTY--- <br /> Gmn{o�n �'vx� ��/� <br /> �p��U�U�U��� �� �^�����U���� <br /> �°v°,o�xxnxx����x-�on` nx~n��nn.�~u~nnn�~xmo <br /> Mobile Food Facility 4Caterer <br /> Complete sections I and2. Ifyour commissary is located outside of San-Joaquin County also-complete section 3..., <br /> |, <br /> hereby state that the above information iucurrent,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 discontinueA the permit holdernotify the EHDFailure to notifythis office result in it <br /> revocation and penalties Z( 2 <br /> Signatul Date <br /> ~ <br /> Address s Bus. Phone (70q) (dL0_ jLj5b <br /> Check all appropriate services provided: <br /> �g Wastewater disposal 9( 3'uonnpadnnentsink 53 Electrical hook-ups <br /> 0� Solid waste disposal [7 Food preparation f9Toilet and haAdwoobing <br /> [AHot & Cold water for cleaning 7Store refrigerated food J3Potable water <br /> WShnredry food/supplies 64-Overnight parking V4Vehicle wash <br /> 1' ' hereby state that the information | have provided iocurrent, 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 to com P with the conditions.of this agreement, or if this agreementi modified or cancelled, the <br /> commissary owner yh_y <br /> Signature Date <br /> The commissary kslocated 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 EHDif the status o/their operating permit changes. <br /> REHS Signature Date <br /> 1868E. Hazelton Avenue | Stockton, California 052DS1 T 20945O-5420 } F 209 464-0138 1w^wvv.,jguvorO/ohd <br />