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SAN JOAQUIN Environmental Health Department <br /> r <br /> 010 N I <br /> cc Q),Nq VIA L,a 1,91 A RV §110 02T11 E_ Ril IF <br /> MoNle Food, Facifity * ca-terer <br /> Cxirnplete sections I anLf 2. If your cornmissaryis,kcated custdfe of Can,1caquin County also complek,secti(an 3. <br /> r.. I.. ed tq),\v7 AP <br /> i <br /> s co ipl <br /> Susines,zs Name <br /> Uc� Plate <br /> 110 ft, <br /> ONuner/Oparstor Name-_ J, �2,_ Go _T) <br /> Business Mailing Address �W_ k,`J ,' ben\CAM I P1 <br /> _- . X. Ph.t Y1C i '� s ° <br /> DAM herelay slate that:the above information is curreni,true and wri-ect to <br /> the best of mny know,"ledge and agree to utilize my approved commissary in accordance �4.4th California Heath F. <br /> Safe W C&Je, and San Joaquin County, i`nvironmantal Health 1[)6partrnent (j=-HV,_"A requimiments. If the use of <br /> commissavyis discontinued,tie permit holdermust-noMithe EIFID. Failure to notifw'this offioB may result in pe.rrn;',. <br /> revocatio(+d Van-altie <br /> L2 La_b <br /> COMMIssary Na me <br /> Address <br /> citK awner/Operator <br /> Check all appfopfiste services provided: <br /> 4fwaistewater dispoew _P-3-compartiment sink JQ Bectrcal hook-ups <br /> jEr Solbd d*-iaste disrposMh ;�--Food pre-paration j3-`f3Uet and han&v&zFn.Mg <br /> Hot&Cold water for cleaning J1 Store vefriaerated food 2`-olaMe waiter <br /> Store dry <br /> y food supplies 13 Overnght panking Q Vehicle wase <br /> hereby state thalt the inforimaVon I have provided Pis Current,true are!' <br /> iJ <br /> c e I le R <br /> crrecrfl.01 e best-Ir rinj knovAedge,and mwz the Ca Hea-M,%I Safely Coat rNat.,irem4nts. If th fo=d facilthy <br /> cperator falls to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> comraissari <br /> GiqnatUre <br /> cbcrplU,slsrit b"', 1'5111h,UICJ 1` <br /> IT(e oomnimsary is lofted in Coup�ihls. The a5hove food, faclfitwl meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above cornmi�.sary_ Please notify' if tj"4z StetLKS Of tl%jr OP`aF2tnG pc_lrM. !t Changes. <br /> REHG Signasture z. inti ............. <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 lwww.sjgov.org/ehd <br />