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SAN-rJOAQUINEnvironmental Health Department <br /> hW:�4. "' J --COUNTY— <br /> `•s:.i- {•' ?�" ureorn sc 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 /> Business Name ¢3000 Y 7ABuCRI � RrU6CA E Lic. Plate# 1-105 <br /> Owner/Operator Name //7,f N0 A A 6E U C-A GU 1'/582E Z 1144 0X)L5Q M LL Lt U Z- <br /> Business Mailing Address 1723 DSL lAfs OR <br /> cityLfFTHROV State ,�2OZip Q5a3Q Bus. Ph(q©$ 6�6�dc�2� Alt. Ph. <br /> I, P,4,flA UCC O CA GU.T-I ER k,-z 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' discontinued, the perm' holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a=n. // <br /> Signature Date 11 (,3 /2 11 Z u <br /> :2 Tobe„cWOOted <br /> 15. <br /> t=,CO`MMISSARYFOW,NER/OPI=BATOR <br /> Commissary Name UN IC 4 C- C7M A<9 'TRU.CK L&fnSTi;l- FA# <br /> Address 1717 S, a01ytS ST Bus. Phone <br /> City676(-Mm ., C{1- Zip MO(, Owner/Operator <br /> Check all appropriate services provided: <br /> (Wastewater disposal d3-compartment sink 0Electrical hook-ups <br /> Solid waste disposal- M/Food preparation dToilet and handwashing <br /> � /Hot&Cold water for cleaningStore refrigerated food FS�Potable water <br /> Store dry food/supplies E)Y'Ovemight parking M/Vehicle wash <br /> I, Ka— ^� � 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 /> commissaryowner all EHD i ediatel . <br /> Signature y Data /�-3 � <br /> �'3 -�To, be con �leted�lj"x'the�`ENuTHEA�TH� unsdtetiiin ottside3of�San'�Joa"utn Cosa; <br /> The .commissary is located in County. The above food facility meets the <br /> commissary requirements in Califomia 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 />