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SAN J O A Q U I N Environmental Health Department <br /> COU IN" VY <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 MCMI CSI 1 05 UL C-AN 0 Lic. Plate# '�1Lf <br /> -[&7Z <br /> Owner/Operator Name DE—FDt l_ C I)RTE z <br /> Business Mailing Address 73q 0 , I-InEP)bfIJ 1 <br /> Cit y5,1 M State CA zip 9,5203 Bus. Phl;-�)z,01 3, 6-3736 Alt. 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 /> revocation and penalties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name u N 101 Q) ytCl' 05A1TC—je FA# <br /> Address (7/ 7 S .. 1L11116 ti S7 Bus. Phone C�2G 9) -?-g$-SL /�-_ <br /> City ,57h � C f. Zip 9/5020 e_' Owner/Operator IME `77_Ci Q <br /> Check all appropriate services provided: <br /> lid <br /> Wastewater disposal 02/3-compartment sink Ell"Electrical hook-ups <br /> Solid waste disposal O FFood preparation ff Toilet and handwashing <br /> 03/1 of & Cold water for cleaning a Store refrigerated food Er"Potable water <br /> :,store dry food/su lies Overnight parking Gr' <br /> Vehicle wash <br /> 6 , 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 sh. !I ti EHD i ediately. _ <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa 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 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 />