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SANa1DAOUIN <br /> Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> cam raw Mobile Food Facility•Oetare, <br /> T � VIoeM2 Mlar[oTmlNery4 AxMalauNJa dayi,pp�yn Caunb a'm tmpbta tttaM�a. <br /> e <br /> oss Name <br /> Owhatl000 alor Neme Lia Plate# <br /> eusinaas Mailin9 raareaa <br /> y`` 2�SlaleLaH ZI <br /> �a � Py circ ays.Ph,�P9.9L(-9999 All,Ph <br /> sl Imy knowlal9e antl 'hO'reOY atala that Ne spore NromeUankwrtenl,uue eM svedb <br /> Safely, enU San Joatluln fqunry E^'alrm+manta�i rHealN 0 ��In e�mm�wpF CON(omb NwIN B <br /> [ommiv^g�y�aismnanuea,tF¢pemiithgaer moat noli(ythe E110.FIlum loNiwllf Wa olrrca maYreaunan owe <br /> evocation ana penallias <br /> SignaNre � � N (-G] � eaten , / /2Z <br /> z-Ta..bacomlefed b-COMMISSARY OWNERlOPERATOR - <br /> Commissary Namur ' Y <br /> / FA# <br /> Address <br /> VI <br /> C {rzLf' /_ In ,( 9 Phone G%- �dG/S''y�S p20 <br /> CRY_:, Qom- r Zip ✓�d�—O"` dOPOPerator <br /> Check all appropriate services Provided: "TTT <br /> at Wastewater disposal 63-compartment sink AElectrical hook-ups <br /> ft Solid waste disposal 13 Food prepamibn ffi Toilet and handwashing <br /> FJ Hot&Cold water for cleaning 13 Store re6lgeratedfcod x,Pelallewater <br /> '` 111.1,1NN/dry�E food//�u�Ipp1%Ovemight parkingg f'Vehidewash <br /> I, /fjt/flies � hereby state that the in{olmation i have provided Is current.We and <br /> correct to the best of my knowledge,antl meets the California Health&Safely Code requirements. It Me food fatality <br /> operelor fat o iorabily with the Oriditions of this agrecmenl,or it this agreement is modhIed or cancelled,the <br /> commissa o shall npti EHD immedl y, <br /> Signature �7vrr-[,a <br /> are VL <br /> o be completedby the ENV HEALTH jurisdiction outside oRSan Jommissary is located in County. The above road facility meets Ne <br /> sary requirements in Califomla Health&Safety Code. The above checked services are available al Ne <br /> ommissary. Please notify EHD if the status of their operating petrel changes. <br /> ignature DateHezehmAvenue) Stockton.Calttomla 952051 T 209460-34201 F 209464-0138 <br />