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L-t <br />(Alt Pf <br />11 th <br />REHS Signature. <br />I <br />Bl <br />I <br />I <br />S'-KI. <br />— — —------- -Dale-Iz.lcs-J2_c..^7 <br />pleted by COMMISSARY OWNER/OP^^^Qp— <br />C>(X\lo 20^- 33^‘C' T, <br />- h-p 6v\U\ _____Bus- Phone_E2^r~5l -I - Z]E - ~ <br />__7in_ q^2HCLOwner/Operator___^fvf. <br />.riate services provided: <br />(^3-compartment sink <br /> Food preparation <br />i Store refrigerated food <br />^Overnight parking <br />$ Electrical hook-up - <br />IX Toilet and han p .', as” • <br />& Potable water <br />{^Vehicle wash <br />hereby state that the information I have pro.'.aec is : .-mr - - 1 ' <br />canceltec. the <br />'Q 34^® I '1868 E. Hazelton Avenue | Stockton, California 95205 | I 209 <br />COMMISSARY <br />Mobile Food Facility , f <br />v,nl/f commissary Is loceted _ <br />Comp** secr^s ^77 AppllCANT <br />. Tc re .-.-1^ byAP <br />Business Name —I <br />Ovner'Opera^ N-r yJ ------- --- <br />? ' ','v^siate C^ZiP-aiiSLBus. Ph(Yxy, <br />. ft-iSQjl________• hereby sta,e lhat 1,10 above 7 <br />I ZYVeYi -^2 arSafliee to utiiize my approved commis% •' <br />1he best of my k"°^n joaqum County Env.ronmental Health Depar-m^, <br />Safety Code- permilho,dermusl n01lfylhe EHD- Fa^'Xcommissary u u - <br />revocation and peng— ---------- <br />Signature^.zLit^Z* <br />2. f0 be co m 1 <br />Commissary Name <br />Address-------X <br />City____L=2^ <br />Check all appropi <br />^Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supphes <br /> , _____— nd meels lnc ______ <br />correct to the best of my know of this agreemenl. or if this ag.ee^nt 5 . <br />" "SXS »“»'>• I,. 65-15 <br /> <br /> , checked sbm-s 3 <br />lit chan9e$ <br />sup! <br />7/) <br />/ with the conditions <br />isaty owner sh^ptify Ujp EHD^ately. <br />S,3natUre__^^X^X^>^^ <br />---------------- 7/ County. <br />above commissary. Please notify EHD if lhe status of their ope <br />Date,.