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SAN sJOAQUIN Environmental Health Department <br />-COUNTY._... <br />C�rravaeus qn,., ! c <br />Mobile Food Facility s Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed <br />b <br />APPLICANT <br />Business Name ._(.5 <br />1A VILQ <br />L' h �c E�,,•, <br />F'C? 5 J <br />Lic. Plate # <br />Owner/Operator <br />Business Mailing Address 103 S I i✓eturf IJr-, by I u) <br />Cityf'k 6M VO- Stated Zip 5-7 Bus. Ph77;--32) --:5Y! G Alt. Ph. <br />I, T -e r -o'10 OAA)ad hereby state that the above 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 end oenalties. . <br />,31.-z-f;zZ <br />1 2. To be comoleted-bv COMMISSARY OWNER/OPERATOR I <br />Commissary <br />Check all appropriate services provided: <br />a Wastewater disposal , O 3 -compartment sink <br />q Solid waste disposal ❑ Food preparation <br />(3 Hot & Cold water for cleaning Q Store refrigerated food <br />1013 Electrical hook-ups <br />Fir Toilet and handwashing <br />'Q Potable water <br />CJ Store dry food/supplies N0ff Overnight parking q Vehicle wash <br />1,, hereby state that the information I have provided is current, true and <br />correct to the best of my kp wledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall_no ify the HD if]7�ll tely. <br />Sianature /�,[�e�7.'�i!�//Gc� i i'- Date <br />.Tobeco <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 />REHS Sig <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />