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S A ._J O AQ U I N Environmental Health Department <br /> is 17,rr!_l <br /> Complete sectlurs 1 and 2. ."f your cor mr &-ssry/s k)cated cutsido of S3- P J08W' CcL«r y also compl`to sx6or. 3. <br /> � I��ILP <br /> RuSires% Name <br /> —�Do op k�An <br /> �,._Co� c�inch-`��-- -------------- <br /> iSu,Sine8S( 'Via iiing Ada�re ;���W 1Jl n CkM <br /> 52 <br /> _— 5 <br /> :1G-ab ;.:bait liE kak U iG c W' ./'F` 1 V6 i.1 11..le, ,+. 1. f if tl sv:} uif l.e 6..•v,-Y Vl t� <br /> tbhe best of rrty :r,owledge and agree tc utilize my approved commissary in accordance vAth California: Health & <br /> f'i' iilC- ;.6.se 3P t1'iE <br /> commissary is discontinued, th;z `,;elder mus'+soUN the CHD. '-ailure io noiiN ihia ols ca.may ;6 ult in pperni <br /> �E"dOti#tlUr � tE� �r2�aiti�5� i <br /> Signature <br /> �e''To ba, =T.Jar9'sllf <br /> Check ail ' <br /> Upropriate aecvices p'rovide.d: <br /> Wastewater di` poses? �,_��8� �71'n°��@�`_ �P�[`� <br /> �''� � .2 Electr:c,31 hook-ups <br /> 801,d waste disposaau v�vl�a pWVi�ps�aese's^;i �a�eeY �o3u tGiniii;Ymea;i�tivvCy <br /> ¢14 E 5.soid Vwaier IOr cleatlin �' 4[lrc CvaCCIt �'C C cu C: ".>d._' „er4lt 4 4c! <br /> �Stx,! dry ® Oae sningggh', <br /> 1. a�,�(e, __ -- -• hereby state Mal the information i nave proviaed is current,true and <br /> correct w the best of.—,V k.��Jdtl4:u `� :� tl"C 'wl!2•w:.;a i'3�-,atLh-C-3ae".i Ccdc' is iiia,:cod C s~ti 2Cp' <br /> operator fails to comply m- th the conditions of this agreement, or if this agreernent i4 modifed or cancelled, the <br /> commissary Owner�te� ' ` �;the El-ND ;.Mr,ed- azel'i. � <br /> o ..o..-. b-a ` etlIM-j _ <br /> w�d u �_ <br /> - _:JJ_N-..22qTjF"'fl � <br /> i tie. cora miss.ry is ;n.__---_ in <br /> _ l2Rite !It :IZOV¢ rnt_u"Ns to <br /> commissary requirement. in GaiiF��rcola a�4iPu1 ; aYety Ctzd!�. <br /> The above fi�t'Y".xed services are avaliatip it jhe <br /> �L�rn�Te�1rrF B@PCt r�!. Pl �s�? C�r?tliy 1�C� t'"tf't st:x vs ^' f??P.C3 C'r ratiC1S n<i,-,Iji' I1r±?D?:. <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 vwvw.sjgov.org/ehd <br />