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—S.ANSIOAQUIN Environmental Health Department <br /> Li COUNTY— <br /> �c� ri Greotness grows here. <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 corn leted by-APPLICANT <br /> Business Name TC(COS _. N I e,Ve. Lic.Plate# ISE N Tt✓V� <br /> Owner/Operator Name �Yld`i 7 t 9'e YNr�e e Z . <br /> Business Mailing Address al o�S �0.�t t OY Y\t n C�• <br /> City L Stat&O Zip%3M Bus. PhC70W Wa-3aU� AIL Ph. <br /> I. <br /> P mr)a e hereby state that the above information is current,true and coned to <br /> the best of my knowledge and agree to utifize my approved commissary in accordance with California Health 8 <br /> Safety Code, and San Joaquin County Environmental Health Department(EHD)requirements. H 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 /> revocati and allies. <br /> Signa re A_�� Date 3 I52 U <br /> 2. To be corn lete1111d b COMLM15SAR1 Y, OWNER/OPERATOR <br /> Commissary Name, �PT1 e P-'T�Y� 1"`� FA# tq C�IrJQ� ' <br /> Address n V us. Phone SSz=7� L7 <br /> I Soo r c I (s%o -p <br /> City��!n FSCc._Iu» ZJp 4S �7t� Owner/Operator <br /> Check all appropriate services provided: <br /> L3Wastewater disposal 'A311,3-compartment sink O Electrical hook-ups <br /> _1 Solid waste disposal A rood preparationA3-Toilet and handwashing <br /> ,dHot&Cold water for cleaning Store refrigerated food O Potable water <br /> ore dry food/supplies O Overnight parking E3 Vehicle wash <br /> hereby state that the information I have provided is current.We and <br /> correct to the b6st of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to compty with the Conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa�ryowner shall not�'th EHD tmmedi ely. <br /> Signature__2 / 166"_ ^ Date 3 /SI Mao— <br /> The <br /> v <br /> 3. To be corn Ieted b the ENV HEALTH 'urisdictiori outside of;San Joa uin Co. <br /> commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health 8 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 /> 1668 E.Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />