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SAN 10AQUIN Environmental Health Department <br />--COUNTY--- <br />_r:,;:.,_.., <br />COMMISSARY AGREEMENT <br />Mobile Food Facility r 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 Ana A"'r--11dw Lic. Plate # <br />Owner/Operator Name R Chorea t/a,�owolos <br />Business Mailing <br />Ph. (.104)3)9-i844 Alt. Ph <br />I, &rr�ar A Chtwea Io(do✓rnos , 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 />CommissaryName /_a &OMimria NA7 mt * FA#, <br />Address /211 5. 144 54-reeo� Bus. Phone (2o4) 33$ —3663 <br />City 140oksh Zip 9535/ Owner/Operator 691d 5 onVe Comm;ssaVo Inc. <br />� <br />Check all appropriate services provided: <br />1, Afar -le Z lws-cry z , 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. <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 />Wastewater disposal <br />18 <br />3 -compartment sink <br />M <br />Electrical hook-ups <br />Ga <br />Solid waste disposal <br />M <br />Food preparation <br />M <br />Toilet and handwashing <br />12 <br />Hot & Cold water for cleaning <br />M <br />Store refrigerated food <br />8 <br />Potable water <br />Iia <br />Store dry food/supplies <br />M <br />Overnight parking <br />® <br />Vehicle wash <br />1, Afar -le Z lws-cry z , 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. <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 />