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COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections f 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 MR lit GCS I SI.A rJ f� 3r1'�Q Lic. Plate# `jSy 7 938 <br /> Owner/Operator NameN �QUIti� <br /> Business Mailing Address ltiS3 tar i daePOf E )✓r l <br /> Cityl\AaxI-�Cl) StateCA Zip S5 Bus. Ph.C/),N�5�-53$3AIt. Ph. <br /> I, P r�tj trVC) , hereby slate 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, an an Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is s ontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p nalties. <br /> Signature DatejjS Z 6) 2 <br /> 2. To be completed b -COMMISSARY OWNER/OPERATOR <br /> Commissary Name CIhrRING Tuck C Nr6 FA# <br /> Address 7 f7 S. 4elooAl 67r Bus. Phonc�2o4��oZ���s`f/ <br /> City"5 R Zip-25.2 0� owner/OperatorT I IRI?Oy <br /> Check all appropriate services provided: <br /> [Wastewater disposal 1297*�3-compartment sink LI(Electrical hook-ups <br /> E!/Solid waste disposal [D/Food preparation [Y"Toilet and handwashing <br /> ET/Hot & Cold water for cleaning U'/Store refrigerated food Lff"�Potable water <br /> ER/Store dry food/supplies a,-overnight parking L9 Vehicle wash <br /> I lflfr Two d , 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 ss 11 notify the EHD <br /> immediately. Date Z o <br /> r� /�/ <br /> Signature // 2 d <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin 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 i www.sigov.org/ehd <br /> SR FORt j fes_, . <br />