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SANAAQUIN <br />COUNTY- — <br />Greatness grows here. <br />Environmental Health Department <br />Coppirassapv AP,RFEraiFNT <br />Mobile Food Facility o 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 _5 XII /9,n (4 /G-4^//0-47.1r Lic. Plate# ED a dc90 <br />Owner/Operator Name /a4 4//4 <br />Business Mailing Address /0eP/1 /-44-pri rfvf It <br />City,_kr..AP1V State CAZip ,S2 0 t3i Bus. Ph.‘ra - ‘5A/t. Ph. <br />I , gficitgLseilli A_2_91_/ , hereby state that the above information is current, true and correct to <br />the best of my knowledg6 an -! agree to utilize my approved commissary in accordance with California Health & <br />Safety Cone, and San „friar-10;n County Fnvirnnmp_ntal Health Department (FHn) mquirernents 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!!alties. <br />Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Deft C,C2A \•FA# 1Q-10303-ZO <br />Address 3 el /WE. Bus. Phone SAO - r7/- ilso7 <br />City wiVed <br />Check all appropriate services provided: <br />Wastewater disposal <br /> Le- 3-compartment sink <br /> 0 Electrical hook-ups <br />Solid waste disposal <br /> 0 Food preparation ',Toilet and handwashing <br />Hot & Cold water for cleaning 121Store refrigerated food <br /> <br />/Potable water <br />Store dry food/supplies 0 Overnight parking 0 Vehicle wash <br />—) cf olc°S! Kj;:ine_S , 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 .;i).-:11 notify the DHD immediately. <br />x Signature - Date 04 <br />, 3, To be completed by e ENV HEALTH jurisdiCtion outside Of San Joaquin.Co. <br />The commissary is located in /2S-- 1_,orsrl 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 END if the status of their operating permit changes. <br />Date <br />A <br />Commissary Name <br />Zip y‘s-vY Owner/Operator 41 Ali en 4.11 <br /> <br />RFHS signet, ire, flats ct-tct-?4 <br />1868 E. Hazelton Avenue! Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 www.sjgov.org/ehd <br />P122LICOBLa