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S A N J O A Q U f N Environmental Health Department <br /> - COUNTY----- <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�RGEP_ H�R { tJ�, Lic. Plate# qb, 15�Z <br /> Owner/Operator Name 0sh t(�: RAM z fl lj <br /> Business Mailing Address 8M E M f k S c,�J C_/ I- <br /> City5ToLV_(06 State (I� Zip '23-2 12- Bus. Ph.V (6 y 95 —600(Alt. Ph. <br /> I, kRsh I)= E fl/n7d/V , 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 /> revocation penalties <br /> Signature Dated (�WCr f/, a O 2 C <br /> 2. To com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name U 11)10 9 C 8162) ILS G 7Q >d 4 Ce5-nl1'CR FA# <br /> Address (7 1-7 S, j,c,00Al S T Bus. Phone <br /> CityET6cK.Tb l� , C6 Zip Owner/Operator1�k l_ (� <br /> Check all appropriate services provided: <br /> [Wastewater disposal E�3-compartment sink .._,/Electrical hook-ups <br /> CR'Solid waste disposal ��Food preparation 2 Toilet and handwashing <br /> 67 Hot & Cold water for cleaning Cd" Store refrigerated food ET/Potable water <br /> U <br /> �to�re dry fo�od/ls�upplliiles Est" Overnight parking E Vehicle wash <br /> I, /nTR C}! ( ( ►t-4 y , 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 owripr shall noti t HD�7imm ediately. / <br /> Signature, Date CI f .2-6 Z' �D <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 />