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/"PS A N J O A Q U I N Environmental Health Department <br /> COUNTY <br /> Grectness 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 „1���,r ifs 'Y'a Lic. Plate# <br /> Owner/Operator Name Rehimcw 01.4.j . <br /> Business Mailing Address ,,, ct�J1,�1 <br /> CitState '.�Zip _Bus. Ph. � pqp �"93'795ZAIt. Ph. <br /> I, 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 discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocatioI-;nr <br /> es. <br /> Signature Date — c?Ll— n <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L k rnl Q g,(_'1 (yi FA# <br /> Address '3ti�`2 i-N� �� Bus. Phone <br /> City s' r^e C&'i-o I-V Zip r14 SIS .S Owner/Operator S"�'T n/Ya M S' /V 1-f Sl! ).,v <br /> Check all appropriate services provided: <br /> ® Wastewater disposal ® 3-compartment sink Electrical hook-ups <br /> p Solid waste disposal [3 Food preparation N�__Q Toilet and handwashing <br /> © Hot & Cold water for cleaning Store refrigerated food 0 Potable water <br /> 0 Store dry food/supplies Overnight parking 0 Vehicle wash <br /> I, , 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 i" nt$FrG0c CREAM <br /> commissary owner shall notify the EHD immediately. <br /> 341E MINER AVE. <br /> Signature L ��^ Date -- 341M MINER <br /> ^. 95205 <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 95265 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />