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SAN JOAQUIN <br />—COUNTY <br />Environmental Health Department <br />1. Indicate the location where you will store food and equipment at the end of the day. <br />Commissary Name: ` eml wT 'I�n� )l,�.� ��y�,.��Faccility ID #: D/00^e2 f7 N <br />Address: v1 a i� . y nern m+C njTX I V l / 0S Goa <br />MENU DESCRIPTION <br />Indicate all the food and beverage items for sale. <br />WHERE WILL THE FOOD BE PREPARED? <br />FOOD ITEM <br />COMMISSARY <br />ON-SITE <br />50A fi ct�rf,d ww\t5 + ve es <br />Coo U_ -- jAja -m M -I-e1�1� -s <br />❑ <br />tkw+- <br />% b JS W CLIA 1 <br />❑ <br />TGCos <br />❑ <br />SO'n C1 w i GIVS <br />❑ <br />j� t C -e <br />❑ <br />❑ <br />2. List equipment and utensils that will be used. Please be specific on equipment's use and function. <br />For example: Equipment: Blender Intended use: Make Smoothies <br />Equipment <br />Intended use during food preparation or catering event <br />Refrigerator <br />5fVy-e_�n,�„nN0 n <br />W„ 1 Lf <br />Ma,k_ sA-s�- <br />g ivy <br />Coo U_ -- jAja -m M -I-e1�1� -s <br />/ri rIvt n �� <br />W& � r u[/f" <br />kze p eV U k L Gi <br />% b JS W CLIA 1 <br />2of4 <br />