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`- SQNdUIQUIN Environmental Health Department <br /> COUN V' <br /> ? : -> Greatness crows here.. REClL <br /> COMMISSARY AGREEMENT � ) <br /> Mobile Food Facility ♦ Caterer =,. o <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin CountNiso complete section 3. <br /> ftt�K110TMeb iP '0ANTk _ 7 +' <br /> Business Name ,o : k Iy� Z✓1 h Lic. Plate# t bX cig 9 <br /> Owner/Operator Name `�jSIeZQS <br /> Business Mailing Address 22/5 � 1 CtCXSC,,) V�UQ� n <br /> City \�C�hlAn State Zip-{S-'J(L7 Bus. Ph.2UCt �-11 Alt. Ph. <br /> 1, �1 4 V i f t'S W Imo\ o If S , 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 andpenalties. <br /> Signature Date q-'SO- 2--k <br /> ,2 To fje eorriI'e`.ted'i* COMMIS'SARY,O,WNEWO`.f?ERAT F�I� � � <br /> MSay' <br /> CommissaryName Za (*Om/3ai-ra 1400les4-o FA# <br /> Address_ 121 t S +� Sf+nef Bus. Phone 6Z0q) 338- 3663 <br /> City A44& sdo Zip 5351 Owner/Operator (nlol 5&2041 C ova i2 c. <br /> Check all appropriate services provided: <br /> li Wastewater disposal 91 3-compartment sink la Electrical hook-ups <br /> Solid waste disposal 1M Food preparation ® Toilet and handwashing <br /> Hot&Cold water for cleaning 13 Store refrigerated food U Potable water <br /> Ut Store dry food/supplies M Overnight parking JIM Vehicle wash <br /> I, LIV?-L , hereby state that the information I have provided is current,true ando. <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. <br /> Signature 'OZ46-17�z� Date- <br /> Ile, <br /> ate Q�3o/zr <br /> m 'nh. , wanarciu: u+,7 hva c- •nc ' t - d Pri� ,i r t^um'u w, ,yam :+: <br /> 3 �To�beseom leted b` qth `ENVu:HEALTH= urlsdiction outs>denof San Joa_ uln CoI,R <br /> The commissary is located in County. The above food facility meets the. <br /> commissary requirements in Califo is Health & Safety Code. a above checked services are available at the <br /> above commissary. Please not HD if the status of their operating permit changers. <br /> REHS Signatur Date Y <br /> 1868 E. Hazeln venue I Stockton, Lie 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />