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PEliS Signature Date <br /> <br />1868 E Hazelton Avenue I Stockton. California 95205 I T 209 468-3420 F 209 464-0138 I omit. <br /> <br />k:V Mncicjii°AQUIN <br /> <br />44Crs. --UNTY----- <br />S A ki <br />Environmental Health Department <br /> <br />' GretOtam rowt hrr. <br />COMMISSARY AGREEMENT <br />fv/lobile Food Facility • Caterer <br />ecifiVIV° 5ectionb ;4 2 If y010 Coirunis.sroy Jocatod otAfrjrki r4e San Jr07 C:rmonty ids° comPlafe secilor, <br />To-bi completed py_APPLICKRT <br />BLISJIVISS Nam o I PC- LI <br />Ownerf0Peratortstarr.e L \J 1 \ V G,I 7- <br />Business Melling Address 11 -6 0 N V\I NI \NI 11 <br />City '1\41 sulfa CA zro MC2(.0 Bus ph. (21, j Opt.pn, <br />'v t 1PC PC2 kVEL retee'xy V.ats Mat rne soave information le ca.rent true and correct to <br />the beet of my locriviedge end agree to mazy my approved commissary In accordance %Ott" Celli:retie Health & <br />Seety Code, rx-d $an Joegt....n County Errveonmental Hearth Deoartment (Ertl)) netauirerrerm tl tne c.rse of tie <br />oorrkirr riaTar e <br />ravool 7 <br />Z To be completed by GOMMISSARY,OWNER/OPERATCA <br />Commssary Name 0\1 1 N t1044.4 <br />Address 111 tD N STIIE ET aus prioriec 23,1) 1—/-1 - 9 f (Lc' <br />City `.±:1-DCTI)N zpc)1S-"ZOto Owner/Operator !LUC I r\:-E T I PP,b 0 <br />Check ail appropriate services provided: <br />Wastewater disposal <br />Solid waste disposat <br />Hot & Cold water for cleaning <br />CT Store øry foodisupplies <br />13 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />Electriutt hook-ups <br />IF Toilet and handwasrang <br />Potable water <br />VeNcle wash, <br />Y E 1 0\ SOC N hureby state that the info tie have provided is current, true end <br />=red to the bast c rny knovAedge, and meet Ca41oma Fleafth & Safety Code reqtarernents_ tl the food tacky <br />orr'erator fole to ocimPlY lhe =orations ot this agreement. or I' ths agreement ke morafiero or conceited. ale <br />nVi V' the EHD immediately. <br /> Dam 1 I <br />To be completed by the ENV HEALTH jurisdiction outside of 8äI in Co.. <br />The commissary rs located In County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. The above checked services are avaqabte at the <br />above commissary. Please notfy EHD if the status of their operating perrricl changes <br />Pale Li 6-12 <br />ine perTr!! horde* rnt notify EHDark,..--e 'to nary the 015ce "ter, resaott en pterni, 1 <br />_pate <br />c.twiwtssaryt ner s <br />Sod/ware <br />,Ya5LNOR