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=� S A N -jJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <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 /> 1. To be completed by APPLICANT <br /> Business Name TAI'MA'ANAO MAN UNU Lic. Plate#5Z51 032 <br /> Owner/Operator Name HENRE' LOSONGCO <br /> Business Mailing Address 1003 Lake Park Ave #130 <br /> City Galt State CA Zip 95632 Bus. Ph. (209) 329-4294 Alt. Ph. (209) 329-7717 <br /> I, Henre' Losongco , 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 disco i ed, the ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe I ' s. <br /> Signature Date <br /> 2. To be com feted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UNION CATERING TRUCK CENTER FA# <br /> Address 1717 S UNION ST Bus. Phone(209) 298-5416 <br /> City STOCKTON Zip 95206 Owner/OperatorART TIRADO <br /> Check all appropriate services provided: <br /> ❑ Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> Art Tirado , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> Signature Date <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />