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SAN JOAOUIN Environmental Health Department <br /> — --COUNTY----- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o� 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 Name SUS A I Lic. Plate# S 6r1 S o8 <br /> Owner/Operator Name Di9ViQ V. TR^nI <br /> Business Mailing Address 10526 �6110W Tr C L11J- <br /> City S+OC140M StateCA Zip g5209 Bus. Ph049) 423- 9Z46 Alt. Ph. A <br /> I, DAV i D V. 71!R^/,j , 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 <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> CommissaryName1/f d o "r m("' & ;rlhy 2xq) y FA# <br /> Address '7.Y VO S. 4-1rQur�, Com' v —_Bus. Phone 7C) �I E <br /> City 5�vr;GL l-v✓1 Zip Owner/Operator <br /> Check all appropriate services provided: <br /> M Wastewater disposal 3-compartment sink Electrical hook-ups <br /> W Solid waste disposal Food preparation I Toilet and handwashing <br /> IX Hot& Cold water for cleaning Store refrigerated food Potable water <br /> Store dry food/supplies Overnight parking Vehicle wash <br /> I --- hereby state that the information I have provided is current,true and <br /> oorre�ct of f 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 shall notify the EHD immediately. > / <br /> Signature Date 7 <br /> 3 To be completed by the ENV HEALTH jurisdiction outside of San Jo a 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 1 Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />