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SA KJ Q A Q U I N Environmental Health Department <br /> COUNTY— <br /> COMMISSARY <br /> OUNTYCOMMISSARY 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 Iq r /1?/]MA rJ ( /i C E'5 Lic. Plate# q 7S 71,19 <br /> Owner/Operator Name t9Rr/4 -TERcs/t 0,, I) w6Z <br /> Business Mailing Address y 7/9 Qa L 4AKE5/'nRq PM,8 2 73 G <br /> city. Sr �Ka'ef� State Ch zip 93:7-67 Bus. Ptf,20 %5'L5-Sc� 7 Alt. Ph. <br /> I,a �q r cb Erc_;�• E2 O fn , 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 Joaqu n County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued f permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. / <br /> Signature Date O g�,I g,;Zl v2/ <br /> be corn leted by COMMISSARY OWNERIOPERATOR <br /> CommissaryName (,( 1t�1 c(� j��) 11 G I lli1CK CL_-' SFA# <br /> ct <br /> Address 1 I-7) S . WA f/opi 5 r, Bus. Phone <br /> CitycJFbc_ T: L)cti• zip 97,��CLr„ Owner/Operator <br /> Check all appropriate services provided: <br /> /Wastewater disposal Cd'3-compartment sink Electrical hook-ups <br /> Solid waste disposal ®/Food preparation L�Toilet and handwashing <br /> Er/HotYHot� & Cold water for cleaning Q/Store refrigerated food uY Potable water <br /> Ci"Store dory food/su /p�liiees U�Ovemight parking Vehicle wash <br /> I, A J 1,T_ �T l (Z1 c 4 C -, hereby state that the information I have provided is current,true and <br /> correctto 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 all notify the EHD immediately. 6/,Z' Z/Z( <br /> Signature Date <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 Califomia 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 />