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SAN. OAQUIN Environmental Health Department <br /> '•4..;r,:,,::.')%"' --COUNTY-- <br /> ' ''�'° v.eTr.^._« grat„z 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'l�ecorn`•'leted�ki" 'RPPL'ICANT,rF°r`, r” T- a h�^ ` "x�� `� �. 3 "� °� �; <br /> rd { qM .Otvl _\-..Av -,41 .^lY• S .r N. i •.h' G'.' <br /> Business Name_y L :VRRS&(,t.1iL-0 Lic. Plate#6G05Y67 <br /> Owner/Operator Name_Al ri*f CSO QE 1-#} 10{7- sERt3lo ✓RR6A5 //ERNRNdEz <br /> Business Mailing Address /3a ISL tF c 16p--CT <br /> Citysrbck-i V State CA Zip .Se20S Bus. Pdzot) 7/S-Y 711 AR. Ph. <br /> I,_dI r&NS 0 htLl—h PR's _, 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, tfLeLpermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties <br /> Signature Date 10 122G2.eo <br /> :2 ;Tote,com`le edhb,`"COM.MISSARY�0IN;NEWOP:ERATOR <br /> Commissary Name ad <br /> 10 Cft'-7 4r=70e JIJ6 ;24f4kF./1 rC-kFA# <br /> Address / 717 -S. taftotd 5T Bus. Phone <br /> City,517'661U, CA Zip25,Z6.6 Owner/Operator lli'19,r7y <br /> Check all appropriate services provided: <br /> 131"Wastewater disposal e3-compartment sink 6"Electrical hook-ups <br /> M/Solid waste disposal M Food preparation f19 Toilet and handwashing <br /> I�HHot& Cold water for cleaning store refrigerated food tLt Notable water <br /> 13 Store dry food/supplies IB Ovemight parking 4P/Vehicle wash <br /> 1, , 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 owne hAll n th EH4i/rt/p�ediately. <br /> Signature ✓ Date/6 12�/y o 2 U <br /> �:3`7oxbe cam"leted}b'``�the�`EIVV;HEAL�TI-1 uris�dictionzoutsiie,ofaSanr`Jda' 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 />