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SAN 10AQUIN Environmental Health Department <br /> —COUNTY- <br /> _ <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquirr County also complete section 3. <br /> 1 . To be completed by APPLICANT <br /> Business Name .549ni4 An* X47-stjhn Lic. Plate# <br /> Owner/Operator Name &-f-ffe; A 06yea Vaiyokmos <br /> Business Mailing Address 1695y a,A&..a« 420 <br /> City 1,1ctn+tca State C.4 Zip V 61 <br /> Qs336 Bus. Ph. (;L04)3td-?894 Alt. Ph. <br /> I, yurrLar A Ch4ve4 LAI&Io✓irros , 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 and penalties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name la Wao6' 0 FA# <br /> Address 12 it S. tea" 54reet4 Bus. Phone (2o4) 33$ —3663 <br /> City 14006tsk Zip 9535/ Owner/Operator Gold 5f*nVe Com nlssora. lnc. <br /> Check all appropriate services provided: <br /> W Wastewater disposal ® 3-compartment sink ® Electrical hook-ups <br /> ® Solid waste disposal ® Food preparation ® Toilet and handwashing <br /> EXI Hot& Cold water for cleaning M Store refrigerated food 121 Potable water <br /> 53 Store dry food/supplies ® Overnight parking ® Vehicle wash <br /> I, /lark Zuzs-Cru lt- , 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 <br /> yowner shall notify the EHD immediately. <br /> Signature Date /D/15/It <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.sjgov.org/ehd <br />