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%N�rcO%� SAN�JOAQUIN Environmental Health Department <br /> t <br /> COUNTY—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 . Tobe com. leted.by,APPLICANT <br /> Business Name ��rvlal�S ���OS Lic. Plate# <br /> Owner/Operator Name v ' (n <br /> Business Mailing Address 6 3q W Amine„/ 4N / - <br /> City State ( A Zip q 5'Z IT Bus. Ph. 2Q�2 4C 1 -919 a Alt. Ph. <br /> I, O.ru rt l (�u 2urti /) • , hereby state that the above information is current,true and correct to <br /> the�e t� 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 rAyo,ej k (/S 7- Date 0-L/0-1 <br /> 2 Tobe completed by COMMISSA^R�Y^ eOWNER/OPERATOR• . <br /> CommissaryName 1� �� 1� 1FCtll.� FA# <br /> Address 2O(]L-5) t� l� h>�iJ� cS�T Bus. Phone U `_7 <br /> City Zip W` Owner/Operator <br /> Check all appropriate services provided: <br /> El/Wastewater disposal O 3-compartment sink O Electrical hook-ups <br /> ,Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> 9140t & Cold water for cleaning O Store refrigerated food 0 Potable water <br /> 0 Store drdry, food/supplies 0 Overnight parking 0 Vehicle wash <br /> I, ` Yil'T'f"I�' c` l�? , hereby state that the information I have provided is current,true and <br /> come t to the best of my kno edge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comp) ith he conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner s I ti the EH m iately. -- - <br /> Signatut Date <br /> 3. To be compMted b he EN _ - L H.jurisdiction outside of-San Joa uin Co. <br /> The commissary is to ted 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 />