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O'JIN`- <br /> z S A G O A Q U I N Environmental Health Department <br /> !=sf' <br /> —COUNTY— <br /> Greatness grows ,here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • 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 6__. RUCK Lic. Plate# q uFR3 91 <br /> Owner/Operator Name kl+7_ 1p Lf 611U(U,9 .9 IRM19 <br /> Business Mailing Address 3S5!y ToO rm Fes$f <br /> City }10M_StateC&Zip7.J Bus. Pt�20jjJT9(p-?5k 7AIt. Ph. <br /> I. /V(TZ IA �_ ZRal A , 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 ust notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. / t ,1 C >pyQ� <br /> Signature-rcyr" �1so— � A)jryjN Jam" Date 2 <br /> 2. To be com leted by COMMISSARY OWNER/OPERATOR <br /> CommissaryName ANION CqjFA/I()6MCk 64tTMFA# <br /> AddressU P416 KI 5-r• Bus. Phon © 9 9 <br /> City 5 roC�_nM Cd Zip L Owner/Operator <br /> Check all appropriate services provided: <br /> lllastewater disposal 04 compartment sink S Electrical hook-ups <br /> I ,olid waste disposal Mr"FFood preparation til 1`oilet and handwashing <br /> EI/Hot& Cold water for cleaning 6.�'Store refrigerated food MPPotable water <br /> iy" Store dry food/supplies lliies M-15vemight parking Cr vehicle wash <br /> 1, //7 I / Iv>ao , 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 ify tk�e E imm iately. [/ <br /> Signature A Date <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.sigov.org/ehd <br /> t <br />