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c°�, S A KJ O A Q U I N Environmental Health Department <br /> " t_* COUNTY a <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 1 and 2. !f your commissary is located outside of San Joaquin County also complete section 3. <br /> �1 . To b.e com l.e#ed by APPLICANT <br /> Business NameKiOnq Xany Pkljgi. S aad Lic. Plate# qHF-111 y <br /> Owner/Operator Name1Gnq Yemlq <br /> Business Mailing Address 10o ol*q 543zd P—r <br /> City �a-M State 6# Zip qS6 35 Bus. Ph. 9o7- 317-- Mtq Alt. Ph. N <br /> I._ N_" "Va'n9 _.. , 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, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties i <br /> Signature Ne- Date <br /> 2. To't'e cornet leted by COMMISSARY`OW/N:ER/OPERATOR <br /> Name _ <br /> Commissary Nam [1� FA# <br /> Address ��d� S �,g�(�/70"2 Z) S-/_ Bus. Phone D f/' T <br /> City �,r��_ Zip 1 Owner/Operator r <br /> Check all appropriate services provided: <br /> � JVastewater disposal a 3-compartment sink Electrical hook-ups <br /> Solid waste disposal © Food preparation ,[T Toilet and handwashing <br /> E' Hot & Cold water for cleaning © Store refrigerated food (rO Potable water <br /> Store dry foodlsu plies Overnight parking Vehicle wash <br /> I, 4ae h , hereby state that the information I have provided is current,true and <br /> correct to the est 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 owner sW notife the E i ediately. r <br /> Signature Date <br /> 3 Tobe corn feted by t ENV HEALTH jurisdiction 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 vnwv;;.sjgov.orglehd <br />