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SANSJOAQUIN Environmental Health Department <br />_•fir ``—COUaVTY <br />Greotnes-s grows here. <br />C0M�� SSS\ICffM[M'r <br />Mobho Food Fadiity ♦ Ca4eror <br />Complete sections 9 and 2. If your commissary is located outside of Saar Joaquin County also complete section 3. <br />I. T� Le coiti��l��tei 6vnPPLICANT <br />ri I <br />Owner/Operator <br />Cosine= Mailing <br />u§ J od e,5- (o state eo4zip 9 535-1 sus. p[�2Oj - 5 F9 - yW 11. <br />D, _%rff,.,3 hereoy suets is _ a current, true ;.end correct to <br />the lost of my knoavledge and agree to utillze nay approved commissary in accordance vritta California Health & <br />Safety Code, and Sar, Joaquin County Environmental Health Department (•f-10) requirements. If the use of the <br />commissary is discon innued, tiepermit holder must notify the U-10. Failure to irairly this c'r,Tice may result in permit <br />revocation „-r,' <br />Signature— �G" / 1� ��2iUc Date <br />Commissary Nam LQ 60WMi SatIt FAS <br />Address idle S. -1+" S4r rp L Bros. ph r'mo_ jr2oq)338 366 3 <br />Cllr �4(ode4#n dip 4 .moi l C vt�r«peratar (A/d s+n�ac Co,,..»;ssvv Inc. <br />Chndk M11 appropriate services provWed: <br />13 ;tevurater disposal )M 3-corrpartrnant sink <br />c <br />J <br />I waste disposal <br />t 'P, Cold water fort deaning <br />Q (Food preparation <br />RI Strnre reaf'rigerated food <br />19 Overnight pa6rirnrg <br />,D MCCtrioai 1100k -rips <br />P "a-iiiet and ihandv.rashing <br />jo P oA'3 le water <br />'a 4i' Nde vaa5h <br />hereby Wtate that the irformation l have provided is current, true .and <br />oaarrtca;t au did nest ur my x04;wrledge, and neeis the rCaliiomla Health & Safety Code req areimients. if the food faciRy <br />operator falh r --r v Aitn the condi ions of this agreement, or if this agreement ir, moaillfled or r seined, the <br />commissaer y the EH® immediately. <br />Stgnature_.%t/orGCr�— ®ate <br />The commissary is ionated in County. The above food facility meets the <br />conrmiscary requirements in California Health & Safety Code. The above checked services are available at the <br />above commissary. PleaW inctify EHIO if the status of their operating permit changes. <br />RENS Signature =_%N `�}YA da - ©ale— - 2 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />