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P-3-compartment sink <br />E:fFood preparation <br />ErStore refrigerated food <br />(3' Overnight parking <br />_a -Electrical hook-ups <br />Toilet and handwashing <br />Al Potable water <br />,ef Vehicle wash <br />:4 <br />SANJOAQUIN <br />. • COUNTY— <br />Greatness grows here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1101406j.npleted by APPLICANT <br />Business Name MA SA LA SVI -dew milk. Plate # 195-;?3.1..a <br />Owner/Operator Name HA-A. A E-E-7- C-#4 6 LIM 14/02. <br />Business Mang Address A5 - WE/ 7--).0k; v E <br />city Spc.44:70,4 state calgip 5°§24 ,J3us. Ph.QC37 6$ 7 „z974Jt. Ph. 4,(.7 ci 7.‘ 09( <br />ay 4-eat- alAtaxgvu.ve_L-. ,hereby state that the above information is current, true and correct to <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. 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 penalties. <br />Signature Date <br />:11:05100i0e106740A11~MM <br /> MOVNIfrteNt-,z,v, <br />Commissary Name IsAav-- M qy-- FA# 5-Z) <br />Address • 2-11--?_, \ik-kck. WCt--k7 Bus. Phone z-s 56 S <br />t \ <br />City \ \17--,b\1 f - Zip 4-1 S Owner/Operator <br />Check all appropriate services provided: <br />rfWastewater disposal <br />pr Solid waste disposal <br />gt"Hot & Cold water for cleaning <br />13-tore dry food/supplies <br />— S niif 144-4_ ,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 shall notify the EHD immediately. <br />Signature — 6..Dve <br />Mi"r12 -Er:4M <br />The commissary is located in (0 0unty. The above food facility th meets e 516 <br />commissary requirements in Califbmia Health & 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 />Date <br />REHS Signature Date <br />1868 E. Hazetton Avenue I Stockton, California 95205 I T 209 468-34201 F 209 464-0138 I www.sjgov.orgiehd <br />?R3St-R-ILk