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$AAOAQUIN Environmental Health Department <br /> t r** z <br /> COUNTY <br /> Greatness grows Fere. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Complete sections 9 and 2. If your comrr�tssary is located outside of San Joaquin County also complete section 3. <br /> I .!-'.'-'r6-be. completed b APPLICANT , <br /> Business Named 106 k C K ld1 P A W _ Lic. Plate#"9313 7 <br /> Owner/Operator Name , Tag� C. hi-HEPp <br /> Business Mailing Address 9631 6 CQERl_ <br /> City_ ht&/N State(IN Zip.916L2 Bus. Ph.(� T 7 S 59--Aft. Ph. <br /> I, ,11 kri A L b l Gt{ERa , 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 diskppritinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and a Ities. <br /> Signature Date <br /> 2. Tobe &mpleted by,COMMISSARY OWNER/OPERATOR <br /> CommissaryName (W(b 6 C!t- K( f�G -ffte- = CI�O'VE FA# <br /> Address t 7 7 s, U N'tn fd 6a'- Bus. Phone a? 02 $-5ql 6 <br /> CityS'2Q TbX (A Zip OwnerlOperator IeL <br /> Check all appropriate services provided: <br /> Wastewater disposal 19/3-compartment sink eElectrical hook-ups <br /> ®//" SSolid waste disposal 1212/Food preparation EKToilet and handwashing <br /> 10/Hot&Cold water for cleaning 03/Store refrigerated food ff Potable water <br /> [�'Sto dry f odlsu linesyy�� Overnight parking 1"Vehicle wash <br /> , 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 owner al no ' EHD ' mediately. <br /> Signature Date /2 Z <br /> F3, To be com feted by the 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. Pie notify EHD if the status of their operating permit changes. <br /> REHS Signature Date 61 3/1&2VC;0 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209468-34201 F 209464-0138 i www.sjgov.orglehd <br />