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SAN JOAQUIN Environmental Health Department <br /> - .....=OUNTY- .. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 0 Caterer <br /> Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> '[. Ta Fie coni `leted;b:` APPILiC/ANT':;. <br /> Business Name �yi�Cura IoaGh ` P r;�H Lic. Plate# 5505X49 <br /> Owner/Operator Name <br /> Business Mailing Address <br /> iCaA' f <br /> City S((p-1c(b,7 State .Zip 9a0*Bus. Ph(,84L() )( 1X Alt. Ph. <br /> I, i'/1 Qu ael hereby state that the above information is current,true and correct to <br /> the best of my ledge 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 gy lll �7 <br /> 1 To=be cram `leted:;b' C IMMUSSARY,©WNER/QP'ERATOR <br /> Commissary Name j PSS FA# <br /> Address- 'f <br /> f ���- : Bus. Phone E G bel <br /> City (�/�( 7ip-A5;Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 131 3-compartment sink Electrical hook-ups <br /> Solid waste disposal M Food preparation Toilet and handwashing <br /> 10 Hot&Cold water for cleaning Store refrigerated food /A Potable water <br /> M Stored ood/su plies M Overnight parking ® Vehicle wash <br /> I, 117 U, U Ci rn -2 Pr , 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 conpions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall n ti the E immedia z <br /> Signature Date <br /> 3 1;6,.b6 corn 'leted b. the�ENV HEALTH`Uhsdiction'outside of.San°Joa uin'Cti. : <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Hearth & 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 I F 209 464.0138 1 www.sjgov.org/ehd <br />