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SAK-JOAOUINEnvironmental Health ®epartmen <br /> —COUNTY— <br /> _ <br /> COMMISSARY ANIfi <br /> Mobile Food Facility* Caterer <br /> Complete secttons f and 2 If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To-to.-Co stet:: APPUCAi+T <br /> Business Nam Yid Deck Lie.Plate# S.5 0/�✓� <br /> Owner/Operator Name 1 <br /> Busine. Mailing Address <br /> city ' W- StatW,' Zip SaOC_Bus. Ph kf 431 - /)5l Alt Ph. <br /> 1,Ala�,,law' 6" ('V o l a hereby state that the above information is curtent,_Irue and corre i to <br /> the bedt of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Departrmt(EHD)requirements. kf"the use of the <br /> commissary is discontinued,the permit holder must notify the EHD. Fallure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature 1tr4; �I a , - Date ! -a i - v2 <br /> To be co ' _ d-b COMMISSARY-OWNERfOP€ 'fv4 OR <br /> Commissary Name L A Cc)tnP,r c% rA� FA# <br /> Address_A01M �-_' "mrkAs Uk Bus. Phone _� U! �'f �j S 70 <br /> City 5 SCJ C kjjk,"n zip A5 ro 5 Owner/Operator <br /> Check all appropriate services provided: ���� <br /> n,E'Wastawater disposal 2" -Wrnpartment sink W Elgtiricel hook-ups <br /> -Solid waste disposal 01 Food preparation �dOT 'let and handwashing <br /> Hot&Cold water for cleaning 13 Store refrigerated food I� le water <br /> 0 SSS a dry food/" res Overnight parking Vehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and me the Cal'domia Health&Safety Code requirements. if the food facility = <br /> operator fails c ply with the r�ndrho is agreemermt or ti this agreement is modified or cancelled, the <br /> commissary urn shell notify the EH rately. <br /> Signature P Date oa�- oaf <br /> 3. TO be completed b the ENV sHEALTH 'tirisdic�ion outs tle sof Sari Joa uit� C�. <br /> The commissary is 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 /> k2EHS Signature Date <br /> 1868 E.Hazelton Avenue I Stockton;California 352051 T 209 468-34201 F 209 4640438 1 wnvw.sjgov.orglehd <br />