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SAN J O A Q U I N Environmental Health Department <br /> - -C OU fel TY--- <br /> COMMISSARY <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 KOSW OS Ru Ci( rt2(tiCk-L.ic. Plate# ii­� <br /> Owner/Operator Name T'�ek �6 !17 ywi e j <br /> Business Mailing Address 120 c - C0aOer �A <br /> City 7-Jf State CA <br /> fZip q S7ZYRus. Ph--IM •i-lW •0110 it. Ph. MI-LA(DId-(400,3 <br /> 0( <br /> I, kxl�(A D MCAC 1�1 , 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 /> commissaryiscontinued, the,permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocatio ndn ti _ <br /> rSignatu e Date <br /> 2. To be c9ftleted by COMMISSARY OWNER/OPERATOR <br /> Commissa Name K OSMOS 1201AO t, (_S� FA+# <br /> y� �L �-, <br /> Address 1D L • V1(%I/(->✓ Bus. Phone'S' � (( t-� •(Q <br /> City 4-j Zip 01ST{E)V Owner/Operator \- `e' nz) 1 n2 v' Reil eA <br /> Check all appropriate services provided: <br /> r3 Wastewater disposal 13 3-compartment sink 13 Electrical hook-ups <br /> Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning 0 Store refrigerated food E3 Potable water <br /> 0 Store dry food/supplies t 0 Overnight parking 0 Vehicle wash <br /> I, P-el L� n-0 (ARf,( t ` , 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 /> commis caner shall no ify the EHD immediately. / �7 <br /> Sign ure, Date. <br /> 3, To.be co feted by the ENW`.HEALTH-,unsdlctPon 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 ),vv,w.sjgov.org/ehd <br />