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Environmental Health Department <br /> SANOAU8N <br /> —�C(}UI\ITY-- <br /> ����U�U�U����� �o�����U������ <br /> ����xmon�xu����»~�o`� xx��"��n'���u�u�nu~o� n <br /> Mobile Food Facility + Caterer <br /> Complete sections 1and 2. //your commissary/slocated outside of San Joaquin County also complete section 3. <br /> 1-0 <br /> Owner/Operator Name 1-0171-0 Mf)V CA OkI, C�LCJi <br /> Ci I nQ3tatXLZip1521-0 Bus. Ph'ZlDq 141tj I 9_bkAlt. Ph. <br /> |, ' honabystate that the above information iscurrent,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 penalties. <br /> Signature at <br /> Commissary Nam <br /> Check all appropriate services provided: <br /> ErVV�6teVvoterdiypnsa| W9-onnnpadmentoink O'E]octrica) huok^upo <br /> 0^�' idwaste disposal G~foOdpr9p8[ab0O 11^To-i|gtand h@DdvV8shing <br /> Cl^Hod& Cold water for cleaning UlSto erefrigerated food blewoter <br /> 0-<turedry food/supplies Overnight parking �� Vehiu|nwash <br /> |. , hereby state that the information| have provided iucurrent,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 | withth did this if this is modified or cancelled, <br /> Signature Data�-� <br /> The commissary islocated in County. The above food facility meets the <br /> commissary requirements in Calffornia 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 /> ' <br /> 1808E. Hazelton Avenue | Stockton, California 852V5 | T2O84G8'342OiF209404'8130 ! vw*vv.sjgovorg/okU <br />