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_ SAN OAQU IN <br /> Environmental Health Department <br /> COUNTY— <br /> COMMISSARY <br /> OUNTY—COMMISSARY AGREEMENT <br /> Mobile Food Facility 4. 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 NameS /aril SKrIOC GR Edd Lic.Plate# 7 7 7-7(5 V 2- <br /> Owner/Operator <br /> Owner/Operator Name FERniAN6)A S PaTAS <br /> Business Mailing Address -9-1 S 7 E. 0 fl S t{r(0 GTS Iv 5T <br /> city. S7-6c4(Tor� StateCT zipc?52(96- Bus. P16202� y3O-/02-( Alt. Ph. <br /> I, FER(J A n)P6 S. R L!i , 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. C <br /> Signature��«c n �a J a Date 3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 61 /O(L' cf_(CRWC--- _F9LLC9 C5NTFi FA# <br /> Address (7 (7 S . r(klmi1 -sr Bus. Phone O�) �{1U� RC2 <br /> City.ST CkTOA , CA Zip �S-106 Owner/Operator / <br /> Check all appropriate services provided: <br /> E/Wastewater disposal 0/3-compartment sink Electrical hook-ups <br /> @,5/'Solid waste disposal tfFood preparation E9 Toilet and handwashing <br /> Hot & Cold water for cleaning 1�f Store refrigerated food Potable water <br /> L Store dry food/su1�lies M(Overnight parking 13 Vehicle wash <br /> I,T CZ ek)b ( ((��� , 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 h II notify the EHD immediately. <br /> Signature Date J3/(Y/o Z l <br /> 3. To be completed 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. 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 />