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Environmental Health Department <br />_Lic. Plate # <br /> <br />'shall noi <br /> Date REHS Signature_ <br />commissary requirements in California Health & Safety Code. <br />above commissary. I ... <br />sanjoaquin <br />COUNTY <br />City S^jpfZip Owner/Operator <br />Check all appropriate services provided: V H () N i?j <br />W Wastewater disposal <br />^S^Sofid waste disposal <br />p<fHot & Cold water for cleaning <br /> Store dry food/suppliesi. yfsii<A <br />correct to the best of my wio^te£lge;ar'J <br />operator fails to comply^f^ie^hj <br />commissary <br />Signature ----------------------------------------Date- <br />; 3T3Jj^mpietedby theENV HEALTH jurisdiction outsideof San JoaquinCcQ <br />. . . County. The above food facility meets the <br />The commissary rs located m ............. ^"above checked services are available at the <br />■ •• • ** • — - - • •— • <br />Please notify EHD if the status of their operating permit changes. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />COmptoro setons , and 2. Ilyollr comm,ss80, /s ,oca,ed oulslde o, Son Joaquin <br /> LUoTe^ompleted by APPLICANT "------------------------------j <br />Busmess Name! 0 R»T I U, f g-1K _________tie. Plate# H W b I 7_ M <br />Owner/OperatorNam e IG? (V/ A CI f) V I LI | | S E ________________ <br />Business Mailing Address I I IP bj UL\ VE AX/L <br />CityjS'TPl^-'WN StateCAziP^5 ?I|5' Bus. Ph/lOq )H3l "1W Alt. Ph. <br />I.IC1/VACI/0 Fl ISFA 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 arid penalties. v > / <br />Signature Cb t/.Date, MH 12075 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name\)N16bJ TpVtK4K/6| bAVSS k <br />Address |717 \J 0 ^T~Bus. Phone! T-Q^) 7--^% ~ <br />,M E I S«« »“"S I ’ !M “■3“" 1 ’ 2M *6"M‘ ' T“ <br />VWMH <br />^3-compartment sink □ Electrical hook-ups <br />^Food preparation Toilet and handwashing <br /> Store refrigerated food SQPotable water <br />□ Overnight parking ^Vehicle wash <br />x , hereby state that the information I have provided is current, true and <br />md meets the California Health & Safety Code requirements. If the food facility <br />lotions of this agreement, or if this agreement is modified or cancelled, the <br />fclmmedlaW. 01/ /H |W25