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SWHAQUIN <br />—COUNTY -- <br />Mobile Food Facility ♦ Caterer <br />Department <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 by APPLICANT <br />Business Name t/n C, `S P/2 -7c( Lic. Plate # I�t <br />�C (D 66 <br />Owner/Operator Name`14 ,e l Q N <br />Business Mailing Address 5Donvt p) r <br />City_ 6 -)CAI StateC( Zip S6URus.Phf7at�'ri23`�8y3AIt.Ph. <br />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 and pe I as. Q p �7 4 <br />Signature i��� l Date V L /Z 3 127- <br />12. <br />ZZ 2. To be completed /b COMMISSARY OWNER/OPERATOR- <br />P Commissary Name z7 C x+wr,'J FA# <br />Address a_ E, 44- Bus. Phone ZO Z r <br />CityCLQ r r Zip -I5ZY0 Owner/Operator .�I G <br />Check all appropriate services provided: <br />wastewater disposal PK3-compartment sink Er Electrical hook-ups <br />V� //o�lid waste disposal Food preparation Q(oilet and handwashing <br />y�Y�Hot & Cold water for cleaning Store refrigerated food P -Potable water <br />W"Storedry food/supplies Wovernight parking R"�ehiclewash <br />1, k7ker r_ la va . f I„ -,y , hereby state that the information I 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 to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />Signature__ �/ �Gv �f-�L- Dater a2 3 �Z2 <br />3. T6Q.' com'leted by the ENVHEALTH jurisdiction outside of San Joa uin Co. <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 Signature - Date <br />1868 E. Hazelton Avenue i Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.slgov.org/ehd <br />