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Zqt�iD/S <br /> CAN WO Erivrlurrrjrerltal Health Department <br /> MAY 1 ✓, 20L <br /> CUMM!`;`:AUY AC1141 I MI N f u,u� <br /> 1 T£,b- GM11..1fete-d by APPt.ICAN I <br /> l,1[�1['i? <br /> - •� "'r<��i'�` I!i, I'r, is(FJ �7�'a��i%� �.f' 1!��lo�i.��J <br /> , . <br /> 11F1r Ufry�>ldlr7 S?I,n tt+er aGnvt+ IrSr,rnrrrE,'.! ,,r'.+.R rr,n? ;nr,r,+r--;1,,,�rar., <br /> bw now to Utilize lily A14mivud c0rnrtnl5rnfy In"".0 noce Wfth r-Allos'nta HeA tI7 3 <br /> wur+ty EnvRnynmuntel Hamill t)opartrrnpnS p=Hp)mquiremorits. if the use of the <br /> t 0,rr,;,�.!n„IIfY Itirl["flp- r"aillFrn?n nlytih�IhiS OlCch[!nrly r.r5uft in ro- -41 <br /> 2 f beCDnpet`ed_ IcyCDMMfSSARY[-OWNERIOPERATOR _ <br /> - .. .� Name- 't(���. FF,:: ��1 <br /> ;ter-�cysar) ].. - <br /> n. l Bus. Phone --LOLL- <br /> ;,�� Zrp Owner/Operater <br /> all ap.mpnate,enrices provided: <br /> .0 jljastewsw, 6sposaf 9113-compartment sink E,;L-Electrical Rook-ups <br /> 6 sobd wwo disposal ❑'Food preparation ❑ Toilet and handwashing <br /> Q HCr;&Colt water for cteanxng V Store refrigerated food 0 Potable water <br /> jt 'S?ore d,•y fa d.supplies �r Overnight parking 0 Vehicle wash <br /> hereby state that the Information I have provided is current true and <br /> mvrw:o tne� oesl of my knowledge,and meets the Califnrnia Health&Safety Code requirements. tf the toed facility <br /> operator falls IQ fyVy with the candilions of this agreement, or If this agreemr,nl is rnodifwd Ur cancelled. the <br /> aomm!ssary sha' tify the D immediately. <br /> Signature <br /> -- -- -Date 'It <br /> ENV HEALTHY OSdiction outside of San Joaquin Co. <br /> The COmmissafy:5 located in - <br /> commissa r � County The at�ovr filed facility meets the <br /> ry equiremen[5 in Cur;ifornia Health & SOWY Cod The atrnvr; checked servlcGs 're 11vailahle at the <br /> above commissary. Please notify EHD If the stalt,i of their 1)[0ratis1f}penr,It change-,,, <br /> REHS SInature — C(��, <br /> �- - Date W <br /> 18u8 E.liazellwt Avsraia J Stockton,Calilomia 45205 1 T 209 468-3424 1 F 2[)9 4134-0138 <br /> J www.sigay.orgfehd <br /> IW2J 1 <br />