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psbc)2 <br />SAN ,JOAOUIN <br />ouNil <br />Environmental Health Department <br />44....p.re- 9r0141 her <br />COMMISSARY AGREEMENT <br />I-uud Facility • Catoror <br />C..urpfete $ection, I and 2. Of )rour commissary Js OCtiterf oudskie of San Joaotoin County atso comploto saction 3 <br />Business Name, <br />Owner/Operator Name u 2_... <br />Bus maing Address I V I Alt: z±A _ <br />C 4 r% -6 StateCA7iA3Y1 Bus. Ph.C\SC -) ':2 1 642J_A1t. ph.201 qq06.1g7 <br />hereby state that thu above inforrnabon Is current, true and correct to <br />th best of nrry k ostrie ge end agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />comrrissary is disoantleued,frr permit holder must notify tho EHD. Failure to notify th , nffice may result in permit <br />ai: "iv / Date 0 --1 /I .° /2. 3 <br />revocation an nate I ) <br />Owner/Operator _ <br />134/astewater disposal <br />iSolid waste disposal <br /> o Fork'. preparation <br />2.•compar1rrent s ni( <br />Ct/Hot & Cold water for cleaning <br /> O Store refrigerated food <br />Ef/Ovemight parking Store dry food/supplies <br /> . herebii state that the info7mabon I have provided is current, true and <br />c/pro..,cil to the best of my knowledge, and meets the C&iforria al & Safety Code requirements. Ii lc food facility <br />operator fairs to comply with the conditions of this agreemenh or i ths agreement is modified Or Ca -r.elled, the <br />commissary owner 1•A1t otify the EHD immediately. <br />Signatare <br />To be completed b(the ENV HEALTH jurisdiction outside of San Joaquin Co, 1 <br />Toe commissary is located In t:NIA:1\A r1::)".\ County. The above food fae lay meets the <br />commissary requirements In California Heath & Safety Code_ The above checked sorvees are available at the <br />above oorrirnissaty. Pfeaso notify EHD if the status of their operating permit changes <br />REHS Signature Date 2.- <br />Ti-tArki. 4E59 <br />1868 E Hazelton Avenue j Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I %wm_sigov.00;f8h <br />L • by,AePL1CANT <br />- <br />#-Th <br />Lic. Plate # <br />Commissary Name <br />Address fE00 Bus, Phone <br />C,11— ZiP VfL City <br />Check all appropriate services provided <br />I ?Jo t?e corr.T._ lete-ci by COMMISSARY OWNER/OPERATOR <br />—FC°' 031(70W <br />Yr7- 7/70 <br />rckft7 AV.F6- <br />S1Electnoat hock-ups <br />'Toile t and nandwashing <br />PrF'otable water <br />chicle wash <br />Date <br /> 2--/I ?-)