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SAN_10AQUIN Environmental Health Department <br /> ---COUNTY ----- <br /> COMMISSARY <br /> --COUNTY ----- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> } t,b�,,�dPPLI3xyry A'''ir �r'd�d tt7 v Gk�'s1 r d i e ul � 3t'h2'+C.sv�+'" .�t;Tobe comIeted , .CANT� <br /> - y LL <br /> Business Name r6`L0 '5 10 6X f C'1 '3eA r6 t7 0 tic. Plate#NR53 96 <br /> Owner/Operator Name SDSc &rhcby RD,DRI oaco Tp L 1P <br /> Business Mailing Address o232y 401V6 4R , <br /> City,5 .1.0 C kTo Il) State Grp ZipSaab Bus. Ph�b`l 55-07. Alt. Ph. <br /> 1,J-0,95- 44FREH Rc09 _Gucci ,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 and penalties. 7/ l <br /> Signature Date /! 7/°?02 0 <br /> To,ye'sm , ted ti; Q1VISOUNERJ R-48A <br /> Commissary Name �fUldA) <br /> M7CKINC Tku�� Cf/UTL-R FA# <br /> Address 17 1� 5. ux (nx< ST Bus. PhoneCZ_q� ,wZ99-5_11 <br /> City�D�E) t C—e p ` tea L Owner/Operator /�T IR if�d <br /> Check all appropriate services provided: <br /> Wastewater disposal d3-compartment sink Electrical hook-ups <br /> I/Solid waste disposal M//Food preparation Toilet and handwashing <br /> EI/Hot& Cold water for cleaning EX/Store refrigerated food :_/Potable water <br /> H SaatooIr-ee dry food/supplies C,l"Overnight parking Vehicle wash <br /> !C <br /> I, 7l I O`b C 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 s II no fy the HD im/m�diately. 7 <br /> Signature - . 7 Date /17 1,2,�I Z 6 <br /> To be codm"ml° ted , NVE Huib*QsdbEeaoSaJoa uirirCok` <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 />