Laserfiche WebLink
_--- __---_-'-___--- <br /> '-` <br /> —~ A-�N~D%JWAT0IN <br /> Environmental Health Department <br /> iM �Y'- <br /> ������K�U����� �o�����K������ <br /> �^v.�omox�vo����x-xoxov~���v��~�~onn�~o� n <br /> Mobile Food FaCility * Caterer I <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name Lic. Plate# <br /> BusinesisMailingAddress- <br /> hereby state that the above information is curnert,true and correct to <br /> the best o[ myknowledge and agree toutilize myapproved commissary inaccordance 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 pef Ifle 7. <br /> Signature Date (, )Z� 12�L <br /> 0W,AW-11C "0$MMWN 01 <br /> Commissary Name � if nit <br /> City-SO& 7 p 0 �W�A '_Owne'r/Operatbr <br /> Check all appropriate services providod: <br /> '/, <br /> [3YVootevvaterdiopooa| �� 3'vonopadnoontnink 0,-fET�eothca| hnuk'upu <br /> 0'So|idwaste disposal El'9oodpnaparation 0"^Toi|e{ and handvvashing <br /> DzKot 'Co|dwater for cleaning Q'stnr frigeratedfood P-11otah|om/mter <br /> ��Sturodry food/supplies EB'�lvernightporking �K/��hiu|em/avh <br /> /_ - ~- �. <br /> |' . hereby state that the information | have provided iocurrent, 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 complywith the dii agreement iomodified orcancelled, the <br /> commissary. <br /> Signatu M6 JA AlfA Date <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 /> REHSQgno1u Dat <br />