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SAN 4J Q A Q U I N Environmental Health Department <br /> -- C O U N T'Y.___.._._ <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 Lic. Plate# �' L ? 73 75 <br /> Owner/Operator Name IVIITlwf Zl���i t1l�c �Z(��-e- <br /> Business Mailing Address 22 3 U 16 T-11err 0 #1 O� � <br /> /� <br /> City n l�I��i C �TState C A Zip�11Bus. Ph\ f� 31-"-5Alt. Ph -o) v 3 Y7 <br /> I,�TDSE 00 ua, AV40662- 96kWW5, ereby state that the above information is current,true and correct to <br /> the best of my knowledge and ana g er a 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 /> revocation and penalties. <br /> Signature ._w��' 0��r �� i Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR —� <br /> Commissary Name �,f/u(Cs ILI C 12 ( 66 //L 6 /' A UC K SFA# <br /> Address / 717 6, 111/(0 also• Bus. PhoneC-,-' U <br /> City 5- b c9T2Dc0, Ch Zip x-6.26 e_ Owner/Operator 4fl'Tesm r 6 ff.4 a <br /> Check all appropriate services provided: -/ <br /> M,'Wastewater disposal Ci/-3-compartment sink in/ Electrical hook-ups <br /> (Solid waste disposal CKIFood preparation ft Toilet and handwashing <br /> M/Hot& Cold water for cleaning Store refrigerated food LY"Potable water <br /> 112-Store d food/supplies lies / <br /> dry pp C�'Overnight parking ervehicle wash <br /> I, �IfiE/�tro I �Y�'Qy 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 own%e shall notify the,FHD immediately. / p <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 vvwvv.sjgov.org/zhd <br />