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SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> _- .. - <br /> CO1HI1 ISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 1 and Z if yourcommissary is located outside of San Joaquin County also complete section a <br /> l o be.Com lated.-b :APPLICANT <br /> Business Name MCdh +'S C6 �1 E" c�7S e5-rl'2o � " � <br /> — Lic.Plate# L/ Rsf/I Sri�q <br /> Owner/Operator Name Ra Pct E/ �Di77ri _/ e Z <br /> Business Mailing Address !1 A g <br /> City 2t /t fl�Statc�_Q Zip gS�Bus. Ph.. ' 3(, Alt Ph. <br /> I,1i �4 0 el oe� ZQ/P Z hereby state that the above infonnadon is current true and correct to <br /> Ole 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. tr <br /> Signatures a�o Pl gy p/ 7�/P Z Date = J/— 26 <br /> 2. To be tom feted-by COMMISSARYOWNEWOPERATOR <br /> Commissary Name 1 A# <br /> Address a�� T— i�trl vr,. L <br /> Bus. Phonee�j �Lj • �( <br /> City <br /> Check all appropriate services provided <br /> �Wastewaterdisposal �+ 3-compartment sink - hilq I <br /> �,ectrical hook-ups <br /> olid waste disposal Food preparation L T flet and handwashing <br /> 116Hot& Coldwater for cleaning ;=a Store refrigerated food ble water <br /> M Store dry food/ pplies UZ vemight parkingj�14 � Vehlcle wash <br /> 1, �� *'0 f /) ��hereby state that the information 1 have provided is current,hue and <br /> correct to the best of my kn ledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply the rti `this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall a EHD imm telt'. <br /> Si atura '� ' <br /> Date. <br /> �L TO bexompreted by the ENV HEALTH jurisdiction outside -ofS.ah Joa uirt cO. <br /> The commissary is located in Couniy. 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, Caliinmia 95205 j T 209 468-34201 F 209. 64-0938 1 vinuw.sigov orglehd <br />