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„punt <br />SAN3JOAQUIN <br />t tati -COU NT Y— <br />Greatness grows here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name --Tei HA I Lic. Plate # 7 7C5-3-77 <br />Owner/Operator Name c-1 (ZAPIAAj s&-:-/eiztyp <br />Business Mailing Address 9 Zo L/A-v&-A)6F-iz 5")” <br />City Alk Ai 76-CA State C4 Zip 3 7 Bus. Ph.(2c40 Z76 - 8.17 S-A-It. Ph. (,ko) 2'3 3- V 3 ci <br />1, i 2xteL4,Q s&s:RA-vioi-i-L-A-10, hereby state that the above information is current, true and correct to <br />the best of my knowledge and 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 />commissary is dis ;Ai , the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation a <br />Signaturey <br /> <br />Date / 2011 <br /> <br />To be completed by COMMISSQRY OWNER/OPERATOR <br />FA# <br />City zip q a Owner/Operator /e. '10 laAiiiteqh gitra_k <br />Check all appropriate services provided: <br />co Wastewater disposal <br /> <br />ga 3-compartment sink <br />13 Solid waste disposal <br /> O Food preparation <br />0 Hot & Cold water for cleaning <br /> O Store refrigerated food <br />0 pore dry food/supplies <br />I eittit/ifi" FA4A64,4(ffr 7-- , hereby state that the information I have provided is current, true and <br />Overnight parking <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails t comply with the inditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary.cyer shall/notify EHD immediately <br />Signature i(2-1'1X <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. The above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Address °Nee e. <br />Commissary Name itettAi a())110 <br />a_2(tit Bus. Phone A/4- likg-116-71' <br />131 Electrical hook-ups <br />J23 Toilet and handwashing <br />13 Potable water <br />el Vehicle wash <br />Date /9