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REHS Signature <br />SANJOAQUIN <br /> <br />Environmental Health Department <br />cou Y-- <br />Greaingts 9foor her, <br />COMMISSARY AGREEMENT <br />MoLufti [-ond I acility • Caterer <br />C implefe septk:os nd 2. ft , vntsswy hackitisf outskir.p of San ..f000ton County also complote t;ncti•on 3 <br />PPLICANT <br />Business Name_ PMf-n(2. <br />Owner/Operator Name ul <br />Bus Mai ng Address I cl Inf, <br />staterilzia3A Bus. Ph. 125 ;2)1 6421 Alt. Ph.D/ (-106 <br />hereby state that the above information Is current, IJuo jnd correct to <br />best of my k ge and agreo to utdize my approved cornrn:ssary in accordance with California Health & <br />Safely Code, a ---d i Joaquin County Environments! Health Department (EHD) requirements If the use of the <br />commissary is ,!.nued,tho permit holder must notify the EHD, Failure to notify this office may result in permit <br />revocation anitttabo <br />. 12; Sianat_ -e 41, <br /> ) Date 0 II <br />[Z To be completed by C MMISARY OWNER/OPERATOR <br />FA# r(io-vim- <br />Addres 1800 g4:4ice- Bus. Phone ,071-1-- 5117- 7/70 <br />City 41/1,,KA cit .15:1Y5 OwnorlOperator_ <br />Cried( all appropriate services provi:ed <br />rerNastew a ter disposal El <br />iSolid waste disposal <br />Et/Hot & Cold water for cleaning <br />E1 Store clry foodisuppiles <br />hereby state that the infor-matan I have providee is current., true and <br />c&-rect to tre besi et my knowledge , arid meets the Califorr ia Heat' & Sa iety Code re;ulrements. If the food facility <br />operator fats to comply with the conditions of this ac.geement or th:c agreement is modified or cancelled, the <br />commissa.ry ow-er stjJl 9otify the EHD immediately. <br />Signatme Date <br />I 37-To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. 1 <br />The comn-tissary is located in LANA .../AA%j\ County. The above food tac lity meets the <br />commtssary requirements In California Heath & Safety Code. The above checked serv cos are available at the <br />above commissary, Please notify EHD if the status of their operating permit changes <br />- <br />Lie. Plate ft Z 2-.--d___592_121 <br />ULe2_ <br />Carnmissa; y Nanle Skeej <br />CI Food preparation <br />C3 Store refrigerated facid <br />12T/Ovemight parking <br />?•-co rnpartment sink LeEiectncal hook-ups <br />eloilet arid nandwashing <br />ja"P"otable water <br />air<ire-hicle wash <br />Date 2-- t .4-62.11 <br />V.-E0AS 5 Liu\ <br />1868 E. Hazeltori Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I ANA' sjgov. <br />S