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Environmental Health Department <br />County also complete section 3. <br />I <br />Lie. Plate# <br />iwledge, and meets the California Health & Safety Code requirements.^ <br />commissary requirements in California Health & Safety Code. <br />Date <br />-^S-compartment sink <br />Z Food preparation <br /> Store refrigerated food <br />^Overnight parking <br />SANJOAQUIN <br />------COUNTY------ <br />Grectnczi jrot*2 n^rc. <br /> LcrW zip ^5230 <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />S'^Hot & Cold water for cleaning <br /> Store dry food/supplies <br />L- COc^xrly <br />correct to the be^tofmy ki <br />operator fails to c <br />commissary owner shall notify the EHD immediately. <br />^Electrical hook-ups <br />S^Toilet and handwashing <br />Potable water <br />©''Vehicle wash <br />•ty ----------------hereby state that the information I have provided is current true and <br />■eit ofmykiWdgS, and meets the California Health & Safety Code requirements. If the food facility <br />_W,!h. “n^OnS of this cement, or if this agreement is modified or cancelled, the <br />~ ■ J ■ I II I II I |\_,UIU ux_» | y . <br /> <br />Signature^^^g^^ Date L - <br />._3._ To be co^leted by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in--------------------------------------------------------County The above food <br />- --------r • The above checked services are available at theabove commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin <br /> <br />1. To be completed by APPI ICAMT <br />Business Name Hflf lAS HfrAfGyg <br /> <br />Owner/Operator Name p'Srftf'VAlHci MOngS <br />Business Mailing Address "??Z> KJCCUH^LL C-4 <br />City.^crlcfrx^---State_C#_Zip OSZiQ Bus. Ph. Alt Ph <br />revocation'and p^a"' P6""" 10 this —It in <br />Signature MClCjC' S .Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR---------------------- <br />Commissary Name -R Galin FA# <br />Address 3SS Bus. Phone 2Z><7-337 <br />City.-----LcrW— Zip 3S2MO Owner/Operator KAqyT(t/g7. <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd