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�pUt,y <br /> SANFIOAO N Environmental Health Department <br /> —COUNTY— <br /> Greatness 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 completed by APPLICANT <br /> Business Name FRLkT�RIA FERnrADI7-A Lic. Plate# 'U61976 <br /> Owner/Operator Name 55M l,961111 lr2 ti/f e <br /> Business Mailing Address la S" rK6N(-H CgM P 06 <br /> City i4lam-clt State C__Q_zip 95336 Bus. Ph.00`f) I 0l' YZ3'6 Alt. Ph. <br /> I. hl6al/olk 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. // <br /> Signature Date 1Z13(ZGy0 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UA!16 (i (47j 6FRI 1.I E -fX1K< 461ti-R&A FA,^#11 <br /> Address 1717 S'_ 61�14-A1 ST Bus. Phone &ov k?8 -r,? <br /> City"fin (OTA Zip !aaz A Owner/OperatorW 7" 150116 <br /> Check all appropriate services provided: / <br /> (Wastewater disposal E3/3-compartment sink I3 Electrical hook-ups <br /> Solid waste disposal CrFood preparation EVfoilet and handwashing <br /> El"Hot& Cold water for cleaning C Store refrigerated foodPotable water <br /> Lx9 Stoo/ree ddt��fovo/d�/,sypplies ®'ovemight parking Cr-'Vehicle wash <br /> I, /T/l ( [ / � , 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 owners noti th Dim iately. l / <br /> Signature Date) <br /> 3. To be com p Ieted by-the ENV HEALTH 'urisdiction outside of San -Joaquin 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 />