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4 ?0?5APR <br />ie <br />DateREHS Stgnsture <br />I S 0K6Ha/fcllon <br />P^SCDS^ <br /> <br />SAN JOAQUIN REC’D f Health Department <br />N I \ <br />v nue I Stockton, Californio 95°05 | <br />la 3-compartment sink Cr Electrical hook-ups <br />j^Food preparation D'Toilet and handwashing <br />□''Store refrigerated food EJ^FJotable water <br />U Overnight parking U Vehicle wash <br />I , 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 />Bus. Phone <br />Owner/Operator <br />Date <br /> <br />! 2. To be cornpi^ed^y COMMISSARY OWNER/OPERATOR <br />Commissary Name'Ve’-.b -FA# <br />Address. Bus. Phone <br />City , /cW?/ /<Zip Owner/Operator ~SfarbajnL A Jn'airfy <br />Check all appropriate services provided: <br />0/VVastewater disposal <br />HJ^olid waste disposal <br />CTHpt & Cold water for cleaning <br />[J Store dry food/supplies <br />46fl 3420 209 <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 ‘ HD immediately. . / <br />Signature Date---------------------------------------------?/------------- <br />[3. To be compietedby the ENV HEALTH jurisdiction outside of San Joaquin Co | <br />The commissary is located in C)/Oo County The above <br />commissary requirements in California Health & Safety Code The above checked <br />above commissary Please notify EHD if the status of their operating permit changes <br />commSSary agreement <br />Mobile Food Facility ♦ Caterer <br />.sections 1 end 2 If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />[ i. To be cornpleted~by APPUCANT <br />Business Name \ ( t <X)A ‘''TpO a Lie Plate# M vj$ \ T 1 <br />Owner/Operator Name Q.C O mVvvAfttxm KariWX ___________ __________— <br />Business Mailing Address.. HL21L_C£hie. \ W____ __________________x_______-______________ <br /> CityThsc^y^^StateCft Zip Bus. PhK 10^11> Alt. Ph. <br />\<v\^, 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, th^pdrift holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penaltips^> <br />Signature