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��0 2 �-{}/ v\3 <br /> {7�7 <br /> � «' <br /> SAN&� |�� � ��� &U <br /> ���0U �K��UU��� K� Env':`�- �7MpntaU Health Depa»tmeDf <br /> -- U NTY -— <br /> IC����N�U������ ��������~�������� <br /> ����omo�mox�^�*~am� n ����u��~��omn�-^� , <br /> Mobile Food Facility 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 by APPLICANT <br /> Business Name io.P|ete <br /> i� <br /> Owne�OpmnatorNam _ <br /> Business Mailing Address 0 <br /> C i us. Ph . Ph <br /> | hereby state that the above information iocurrent,true and correct to <br /> the best ufmy knowledge and agree to utilize my approved uumm|noery in accordance with California Health & <br /> Safety Code. and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary isdiscontinued, the permit holder Must notify the EHD. Failure tonotify this office may result inpermit <br /> revocation <br /> Signature...._ h —Date (A 14 1 I-K- <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Co[DnliaoerV Nam <br /> Aidrea ua. Phon <br /> C i wmar/Operato <br /> Check all appropriate services provided: <br /> ,� w� ,� <br /> ���VVaatewaLerdi�poaa| ~� 3-o�rnpa�m*ntoink ^// Electrical hook-ups <br /> + -�So|id waste disposal -Zf Food preparation ~ Toilet and handwosh|ng <br /> Hot& Cold water for cleaning ' Store refrigerated food Potable water <br /> Store dry flood/supplies Overnight v8 <br /> parking �� Vehicle wash <br /> ` <br /> !, hereby state that the information |have provided iscurrent,true and <br /> correct tothe best ofmyknowledge,and meets the California Health&Safety Code requirements. Ifthe food facility <br /> operator fails to comply with the conditions of this agroemont, or if this agreement is modified or canoeUed, the <br /> commissary owner shall notify the EHDimmediately <br /> Signature -Date <br /> 3. To be completed by the ENV HEALTH jullisdiction outside of San Joaquin Co. <br /> The commissary is located in SAC(74V-A" Ca,, County. The above food facility meets the <br /> commissary requirements in California Health & Safety ove checked services are available at the <br /> above commissary. Please notify EHDifthe status oftheir operating permit changes. <br /> REHS Signature Amte_____/_ <br /> 1888E. HaZe|U:nAvenue 1 Stockton, California 052U5 / T 209468'34201 F 20Q484-D138 |www.sjgov.org/ehd <br />