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SAN JOAQUIN Environmental Health Department <br />Complete sections ' ana 2 <br />rue anc <br />REHS Sigrature Date <br />revocation and penalties <br />Signature____» <br />^3-companment sink <br /> Food preparation <br />S< Store refrigerated food <br />Overnight parking <br />___FA#_________ ________ <br /><209^ <br />Electrical hook-ups <br />i oiiet and hanowashing <br />'M Potable water <br />Vehicle wash <br />J-ic Plate# <br />ft We co\ <br />*^2______Bus Phon' <br />Owner/Operator AtejC<\c\(O OCVlOfl //^6Y16<y <br />3. To be completed by theOftFHBMJTH jurisdiction outsMKof San Joaquin Co <br />me commissary s located m County The above fooo fact ity meets the <br />commissary 'egui'ements California Healtn & Safety Coce 1 ne above checked serv.ces are ava. abie a: tne <br />aoove comm'ssary Please notify EHD if the status of their operating permit changes <br />'35c E r-aze m-A;e-.= StccKto'' Ca fem a 95205 T ^68-3420 F 209 464-0138 ■.s zo. cm em <br /> <br />rfy knowledge, and meets the California Health & Safety Code requirements' r're food facTi.ty <br />o' cancehec tne <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />< your commissary is located outside of San Joaquin County also complete secrcn 3 <br />JLIobe completed byAPPLiCANT "• . ------------------ <br />Business Name <br />Owner/Operator Name <br />Business Maying Address <j I f ( Mu'ftc4 /S Ou cj <br /> <br /> State_^Zlp_n1jJ^Bus Ph Ph /6 - <br />the bpCt^n^r-\ Ann i h ---------------— nS e°y s's:e :^aI lfle accve information is current true ano correct :c <br />Safetv Cone ano A my aPPr°VeC commissarV m accordance W,th Cahforn.a Healtn &rnm‘y^ d S P JOaqu'n County Environmental Healtn Department (EHD) requirements if he use of the <br />“T * !S pe“Xuea ‘ne perm"h0Wer mtJs: noW tne EHD Fa"ure 40 th,s office may r“ult ,n ae™t <br />TIami-iL-Ja_______________Daie P <br /> 2. To be completed by COMMISSARY OWNER/OPERATO R ---------------- <br />Commissary Name Cl'AW ffi | sSCyrU <br />Address (.Oze) fe-&C<CCCX\\.CA-lC7 <br />crtyixdd______zip ngz-HO <br />Check all appropriate services provided <br />'Sf Wastewater disposal <br />ZT Solid waste disposal <br />X Hot & Cold water for cleaning <br /> Store dry food/supplies <br />CO(WkY\—VT6V ectf hereby state that the information I have provided is cumem <br />correct to the best cfttI] <br />operator fans to comply with tne conditions of tms agreement or >f this agreement is modified <br />commissary owner shall nonfy the EHD immediately <br />Signature Date