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tronmental Health De��� <br /> GQU -- <br /> iv'ioiJle: FCy a0' , mel'bpi 1- <br /> Cornplata sec°uons 9 and 2. d;yourccrnmissary is foretad ouisfde of Sen Joayuf i County also complafe sauffort 3 ., <br /> $o y i7c �1 ilatet'I;*APRUC T. <br /> Buslness Nam Tar �.v m Lic.Plate# 455 24s 1 ) <br /> Cwnerr4?R�r9tQe i= L��� M a'K7C+1 �,.f rf 'F <br /> Business Mailing Address, 11 -9e l V r t/e <br /> Cid :stela ip Bus. F4.90 2'rG Ph Cl Z _-7'3'-r <br /> Rc—t0 Mono hereby state that the above information is current true and correct to <br /> :he best of my In, owledge,and agree to utilize my approved commissary,-in accordance wilt Cal'linmia Health & <br /> Safety Code, and San Joaquin County Environmental Health Department(EHD) requirements. If the use of the <br /> commissary is discontinued,the permit holds,-music notify the ERID. Failure to notify this office may result in peg snit <br /> revocation acid penalties. <br /> Signature fl A✓1- 6"rrRnmi srrgr">e4 Date <br /> 12.-Tobecornplated, Y-COMMISSARY OWNMOPERATOR <br /> A <br /> Commissary Name L Ty` <br /> Address ?�!�� � era-Lsawy�,u, Bus.Phone <br /> City 1 c!{� iiia vy fir= Ownerl4per2tor �'�rs; r; _Yl t <br /> 'z <br /> Check all appropriate services provided: <br /> Wastewater disposal ; 3-cornparnnent sink El cal hook-ups <br /> solid waste disposal ` Food preparation u Tflet and handwashing <br /> ®f 8 Cold water for cleaning Stare refrige[aied foodstable water <br /> Store dry fopolsuppiies 'Ove night parking Vehicle wash <br /> O pt T 6- <br /> f, ( � rCi✓t Y ���J2 ,hereby sista that the information i have provided is current,true and <br /> correctto the best G my! edge,end meals the Cal fomia Health&Safety Code requirements. If the food facility <br /> operator falls toof this agreement, or if this agreement is modified arnceiled, the <br /> commissary ovmer shall ,, the EHD r ectiateiy. <br /> rpn3tE:rV Dale <br /> !,aa by a 'a EX"! 'uradictiori oubiid d Sal`. .Joaquii`? . <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 ii the status of their operating permit changes. <br /> P,EIS Signature Date <br /> 1808 E_Hezeiton Avenue I Stecicton,is?Itemia 35206', e 2132 460-34201 F 209 464-ri eafi ;vuv w.si otr_or -feht <br />