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SAN,lOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness, <br /> COUNTY— ����'��® <br /> '+ Greatness,graws here <br /> COMMISSARY AGREEMENT JUN 2 9 1020 <br /> Mobile Food Facility♦ Caterer ENVIRONMENTAL HEALTH <br /> Complete sections f and 2. If your commissary is luted outside of San Joaquin County also comple elsesga VJC ES <br /> 1.Tobe com leted b(APPLICANT'_ <br /> Business Name m 1 Eb Q•eQ Lic. Plate# <br /> Owner/Operator Name�7_1!,Q12n\ CC 'c <br /> Business Mailing Address�� o Crie 1LroC \ <br /> CityI *mt-krAn State_CLZipaG3.WBus. Ph. Alt Ph � a5q`6 <br /> 1, E Z o U,1 P\ c` o t'O ,hereby state that the above information is curen%.true and correct to <br /> the best of my knowledge and agree tolutilize my approved commissary in accordance with California Health & <br /> Safety Code, an a JoaquinCo unti,Environmentai Health Department (EHD) requirements. if the use of the <br /> commissary is soon ued,the m(Whoider must notify the EHD. Failure to notify this office may result in permit <br /> revocation and n (� <br /> Signature Date <br /> 2 Tobe-Co le`ted,b COMMISSARYOWNER/OPERATOR : j. -.. . <br /> Commissary Name L A Ccs GNPs C i r„ FA# <br /> Address (' Bus. Phone a0ci• 0661 - <br /> 66I • "-/570 <br /> City ��0 C g_kyn zip Owner/Operator Onl C) A Cf12kt• <br /> Check all appropriate services provided: <br /> jgrWastewater disposal W 3 compartment sink cal hook-ups <br /> solid waste disposal Food preparation T let and handwashing <br /> ® Hot&Cold water for cleaning 1 Stole refrigerated food ;eC water <br /> 0 SSttorree dry food/supplies G—YO/vemight parking Vehicle wash <br /> I, l c�ye� 1,'L , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the Callfomia 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 r/�nshall no/�rfy the EHD imme&ately. <br /> Signature �/Y/ Y/ �i� Date1)une �"I , d�� <br /> 3. .6be corripldt6dty the ENV HEALTH.'uftdiction outsidd'of San;loci uin'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 ifthe status of their operating permit changes. s <br /> RENS Signature Date <br /> 1868 E.Hazelton Avenue I Stockton,California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />