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Date: 10/15/25. <br />Trash, recycle, organics) <br />I Date ReceivedReceived ByPE#TE# FA# <br />RfVlMTf: 7/15/20’5 <br />for office use only <br />CONTRA COSTA • ■L <br />HEALTH <br />| Assigned to <br />J Gin <br />l^^dlThe FoS Vender in Section <br />Hand washing sinks <br /> Food preparation area <br /> Food preparation sink <br />■TO 3 Compartment warewash(dish) sink <br /> Refrigerator/Freezer storage <br /> Cooking equipment <br /> Dry food storage <br />I certify the . — <br />"6wnerPrintedhiame?__ <br />■^ rn RE^COMPLETED BYJJUTJDF <br />The above listed Commc— <br />REMS Signature: -----i <br /> Email: <br />CONTRA COSTA <br />ENVIRONMENTAL HEALTH^DMS^ <br />2120 DIAMOND B ^cord CA 94520 <br />-----------^^i^L'FR°RSloOOD .FOR TEMPORARY FOOU e ------------ <br />1. TO BE COMPLETED BY FOOD VENDOR <br />Name of EventPemon hunter fanjest----------------------- <br />Event location.790 2nd street Brentwood^ --------_ <br />Food Vendor Name.House of ice cream <br />Mailing Address (City, State, i . . <br />Phone Numbei2092786096 <br /> County. I <br />inspection status is compliant and has capacity for <br /> DateiJCjM^ <br />---— — [Eve n£Date(s)1vo^ <br />F^dBoTtlTNameHouseoU^cream-------- ---___ <br />Zip)^ s q^eld st #15 lodi ca 95240 ---------_____----------— ' <br />-----------------— pmaii^nd^o^z^rcom _ ^^kKowledge^ <br /> Safety Code.---------------------------------------------------------------------------------------- <br />Signature:----------------------------- <br />Print Name: Rodencktyfer-------------------------------- »___________ . AuumFR <br /> 2 TO BE COMPLETED BY COWIIERClAjjPggD^OAgEg-------------- <br /> <br />CnmmprciallProduction Kitchen ----------------------------------------------------------------------------------- <br /> ppnitity AridrASS (Citv7sUtrzip)B20 , -------------------M--------■------------7 rrwfA rphone7iumberg^22^2y|---------- <br />Operator Name.^^^^ available). <br />” ■" Seoti00 W,t n lce machine or food cooling equipment <br />Potable water <br />J2 Disposal receptacle(s) (ex <br /> Equipment storage <br /> Chemical Storage <br />Restroom with hand washing sink I <br /> Mop sink -I <br /> <br /> <br />KTr V\CCl Owner Signature./^4^?-^ -_ <br />72T7~^COUNTY AGENCY <br />lercial/Production Kitchen is permitted in <br />The above listed Comntercial/Production Kitchen i <br />this Food Vendor. <br />REHS Printed Name: Af Q— <br />Phone Number: ,.^21—--------