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SANIJOAOUIN <br />--COUNTY-- <br />G.-fawn rrorrs insrn <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />WNW Ecc-d Facility Catere7 1(6 -. '2 <br />C-CIMpitife sections and2 ur COMMiSSEtry Is lar..il=rd fid of S'an Joaquin County also cvm,rd1/4449 <br />To be completed by APPLICANT <br />Business Name gi 12>g_Os p Lim Plate #_EZ.2.i_lr_Na.}. <br />Gilmer/Operator Name_1,'Le <br />Business Mailing AddreKse3i I S St 1it A Laxe(Ac:-/- <br />city_yTOCi(7i,,v stateC4- ,Tipq-29.u3 Bus. Ph-20cl -29 a" /cp-ilit. Ph. <br />17_CetKi(4- e--;c;k1A;-,,,,L1 herebys-r'.p4e that the above infoim-atori is current, true arid correct to <br />the best of my knowledge and 'agree to utilize my approved commissary In accordance with California Health & <br />Safety Code, End San Joaquin County Envtronmental Health Department (EHD) requirements, It the use of the oomrrimsary ntl •, the mus.. notify the =HD. Faicum XI notify this office may result In permit revocalien a <br />Signature <br />Commissary Name_lj A# <br />Address 7 ,' `.,3 • jj. <br />city p OwnedOperator azlk <br />Check al: appropriate se.rvices provided: <br />Vvestoweter dsposal /11M 3-cornpartrnont sink <br />Solid waste disposal Food preparation <br />e2S) Hot & Cod wair for tleaning pt Store refrigerated food <br />Store pariog <br />sigrature Date <br />a_ To be completed b-l-the'ENV HEALTH urisclitUon outside. cif -San_.40a0tiin Co_ ' <br />The sammissary is located in County. The above food fality meets the ,dommdmery roci10-emcmS in CalUomia Health & Safety Code, The above checked sericep, are evaliable et the <br />above COMMiSSarY- Please notify DAD if the status of their operating permit cheNes. <br />RS Signature Date <br />18,38 E hialmitdri Avunut: SiOck.V1, Caltitrnio g5205. 1 T 2OS 468-3423 F 2N464-0138 1 wwwAtov.orgiehd <br /> Dt C <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Phone 7 oft zq - - <br />—"Remo Lu <br />dry food/supplies p7Overnight <br />Electrica°1 hook-ups <br />ja Toilet and handwas.hing <br />Potable wate.r <br />pCiehicle wash <br />Li/PfN ):K8 3 0364 , hereby state that tle in, an t have provided is curret, tue and COrreC lo the best Qa- My knowiedge, and meets the Cgifornia Health & Safety Cade requirements_ if the food facillty <br />=orator fails to corivfy with the condftions of this agreement, or if this agreement is modified or oar.ce;led, the ccmm-ssary owner sh ;I r Lraimmediatelv.