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SAN JOAQUIN Environmental Health Department <br />—COUNTY— <br />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 />1.1. To be completed by APPLICANT ' Q <br />Business Name MMiZigCo� MciZ-4-I 14 J MerirC,Lic.Plate#SC6jq(P`_I1 <br />1 <br />Owner/Operator <br />Business Mailing Address 1`125 V-ee17 C=1 l V1 IJ/" . <br />City 5H&Vj_V)1q StateZip ZD(pBus.Ph.2061 CA9 (POZ. Alt.Ph.W"l 5212 (ptOL4 <br />I. V(AI et 1 f7lJ (ju), )!m L(1 '►T , hereby state that the above information is current, true and correct toy <br />the best of my knowledge andagree t tilize 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 ya I 6 A /'n Ca N 20.1 C Date <br />12. To be completed by COMMISSARY OWNER/OPERATOR I <br />Commissary <br />U <br />Address 2-V90 S. Atepari— W.+; Bus.l <br />City S1-br_4 u -i Zip gs-206 Owner/Operato <br />Check all appropriate services provided <br />Wastewater disposal Cr 3 -compartment sink <br />olid waste disposal d Food preparation <br />Hot & Cold water for cleaning Id Store refrigerated food <br />d'Electrical hook-ups <br />eToilet and handwashing <br />/ elPotable water <br />Stone dry food/supplies CI Overnight parking F3 Vehicle wash <br />1, 1� s S 2vb�a 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 shall notify the EHD immediately. 9 <br />Sinnature ,( _ nafa 1.0 / / `7 k / <br />Irelsm- <br />the ENV HEALTH <br />The commissary is located in <br />commissary requirements in California Health & Safety Code. <br />above commissary. Please notify EHD If the status of their ope <br />REHS Signature <br />1068 E. Hazelton Avenue I Stockton, California 95205 1 T 209 46 <br />7007 <br />