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—COU N E 5 ... .. <br /> )ii •• <br /> t��iCtlaEi� ta�Grd k' r`..''.wet ii,�f?• �+ei'��,'r:- _ ._. . <br /> Compiefe secdons 7 and 2. If yourcornmissarr/s feted onside of San Joaquin Cotrniy also compiere section 3. .. <br /> 1oToWCOMn[2t6dibYAPP.LIc <br /> Business Nam4.�C,!_C-1ki-e(C) Lic.Plate '06 SZ <br /> Owner/Operator Nlar,ta Raj M a '70M (1 Cr re � <br /> Business Mailing A,ddrre�ss a IU r /-f-�1 <br /> (/'2 <br /> fifty �� I� [eipbus. Ph 6Q It Ph G Z 77$S <br /> I, a i I Mo nw hereby state that the above information is current vue and correct to <br /> the best of my knawiedge and armee to utilize my approved commissary in accordance with Cal fomia -earts & <br /> Safely Cade, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,the permit holder must notify the EFID. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signaturis_AA ✓1- G*aNON Svcre4 pate 0 2 B �aGaU <br /> '.-.j$SARY OWNEIRIOPERATOR <br /> Commissary Name � 1 i. ��dFn�.0 �. r; '; FA# <br /> Address 6aLma uoc".. Bus.Phone <br /> City �J�i Cj C zip Z p j Owrer/Operator <br /> Check all appropriate services provided: <br /> s'/Wastewater disposal E/3-compartment sink - a ElWrical hook-ups <br /> eolid waste disposal ` Food preparation e1E !let and handwashing <br /> W®t&Cold water for cleaning ^ Store reirigsreted food stable water <br /> OStore dry fo d/suppiies _'Overnight parking l/chicle wash <br /> I, (� • e �� &r W-c fL- ,hereby state that the information I have provided is current,true and <br /> correct to tha best of my owiedgs,and masts the Calffomia Health&Safety Code requirements. If the food facility - <br /> operator falls to comply th ndit7ons o,Phi <br /> • s agreement, or if this agreement is modified or cencalled, the <br /> commissary ovmershalltha EHD E eoiately. r1 <br /> Egnatura " nee 6c( 12 Q �ROAO <br /> I 1. i'd: `_ . . = v �.Slt 6flt5i.dn Cc <br /> The commissary Is located in County. The above food facility meets the <br /> commissary requirements in Cal•Efomis Health a 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 /> PP-HS Signature Date - <br /> ISOS E.Hazeitan Avenue j Sieck on;California 952115`. T 269 4'3e-34201 F 209464-0138 E wtyw.sit ov oreteh <br />