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SAN?1.0A UIN <br /> Q Environmental Health Department <br /> i i. "J . —COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility m Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> >1 �To b'e�corn letecl ti".RAPRk"10 <br /> Business Name GL 2RRSQut4t0 Lic. Plate QGOKYG7 <br /> Owner/Operator Name_d4r,9, LSO a 1-If 1°192. 4 49ER610 ✓RR6A5 HERNANdEL <br /> Business Mailing Address /3.2 G 1_ac I Ex -CT <br /> Cityff,t c . <br /> jkAj State CA Zip Ed46�- Bus. Ph(�p) 7/S-y7// K. Ph. <br /> 1,�1 rA6NS 0 QeLA't P1+7- , 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, rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties <br /> Signature Date_ <br /> '2To,{te,com' °le ed3b:° 1COM:MISSARY�000NEWO,RERATQR ^ <br /> Commissary Name j2d/0 Cf47-4�70Q1416 244 f T-C-kFA# <br /> Address t 7/ 7 S, o 0o fd ST. Bus. Phonne�rt� <br /> City.MCM, to 7095,26 ,�1�/C.6 Owner/Operator 111fiV'-� <br /> Check all appropriate services provided: <br /> (Wastewater disposal e3-compartment sink lectrical hook-ups <br /> M--" Solid waste disposal M Food preparation VToilet and handwashing <br /> lil//HHot&Cold water for cleaning store refrigerated food & /Potable water <br /> L3 Store dry food/supplies LB'Overnight parking 44ehicle wash <br /> I, , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, and meets the CalHomia 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 h n ' nth EHCZi ,ediately. <br /> Signature_[/�� Date J O 2 2r/2-o 2 U <br /> [;6,r`>o`}b'e_corn Ietedrb' ttie EfVU�HEALT <br /> * R urisdlctron>outside ofsSan Joa 'uin Cod? <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 />