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SAN- OIN Environmental Health Department <br /> * <br /> —COU NTY-- <br /> G, j�/c <br /> ����U���K� �o�����U������ <br /> *+��x�xx�nn�p"�x�m`� mv~��po��~�~n�n�~n� o <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 /> 1. <br /> Business Name ic.P|8te <br /> Owner/Operator Name <br /> Business Mailing Address ; !I 4L <br /> hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to utUfflze my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Enviro nmental 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 andpename <br /> Signature a " <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary N_m— <br /> y-at a Bus. Phone <br /> Check all appropriate services provided: <br /> 112/WaLts*vaterdiopoea| 13 <br /> ,,a-n0n1partn\eAtoinkCrBectrio8l hook-ups <br /> CkS]|idwaste disposal P,FoodpreparatioO ���/|niletnndhaDdwKashing <br /> Iot Id water for cleaning Ey's ore refrigerated fbod qPVtab|ew/ater <br /> tore d 0 food/supplies Volvernight parking CYVmhic|evvoah <br /> |. . hereby state that the information | have provided iacurrent, true and <br /> correct tuthe best ofmyknowledge,and meets the California Health&Safety Code requirements. /fthe food facility <br /> operator fails hu comply withthconditions ofth'S agreement, or if thi greement Is modified or cancelled, the <br /> commissary o ner shal ofify the EHD immVia ely. ,,, I�� <br /> Signal Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary ia 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 commissary. Please notify EHD if the status of their operating permit changes. <br /> REHG8ignoture Dat <br /> 1050E. Hazelton Avenue | Stockton, California S52U51 T2O8408`84Z01F ?OS404'O1301vmxw.sjguv.org/ehd <br />