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PR 0s3 6 39 <br /> SAN JOAQUIN Environmental Health D��. nt <br /> �L 'JUNTY - <br /> - <br /> SFArasuusco � <br /> COMMISSARY AGREEMENT t LULL <br /> Mobile Food Facility e Caterer <br /> Complete sections 7 and 2. If your commissary is located outside of San Joaquin County also completerC$ti�iii 3. <br /> 1. To be completed by APPLICANT , 1 <br /> Business Name The, Chu t-YD S per}' Lic. Plate# e) <br /> Owner/Operator Name w IGI ad O&oq <br /> Business Mailing Address 27710'? SAWIowbYODk- W6Lq <br /> City VL1 VS-N) StateL))Zip"Bus. Ph.aO'1"061-190� Alt. Ph. <br /> I, f WC-Via d 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 END. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Ez; � Date z il-a a <br /> 2. To be completed by COMMISSARY OWNEWPERATOR <br /> Commissary Name La �Om "ia Z4�45h' FA# <br /> Address 1211 4. 7'11 _54y-egj Bus. Phone (za!)33,9-36c 3 <br /> City_Z&2 azl-o Zip 1i53S1 Owner/Operator 1,,,,1/ ,5 e y, the <br /> Check all appropriate services provided: <br /> Stani <br /> je Wastewater disposal R 3-compartment sink )ZI Electrical h ' <br /> 13 Solid was disposal 13 Food preparation M Toilet and I <br /> M Hot&Coldwater for cleaning fel Store refrigerated food Il Potable wE d <br /> A Store dry food/supplies H Overnight parking k7 Vehicle wa ' aryl <br /> I, �ar� /ur S-C/V� , hereby state that the information I have provided 1 MARY-KATE COOK 91 <br /> Senor Environmental Health <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. Specialist <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified ENVIRONMENTAL RESOURCES <br /> commissary owner shall notify the EHD immediately. Environmental Health Division <br /> Signature <br /> Date� 3800 Comucopia Way,Suite C <br /> Modesto,CA 95358-9494 <br /> Direct:(209)525-6713 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San! Main:(209)525-6700 <br /> � Cell:(209)505-7388 <br /> The commissary is located in rQt1t`7,Q1I County. The above food Fax:(209)525-6774 <br /> commissary requirements in California Health & Safety Code. The above checked services a Email:mkcook envres.or <br /> — <br /> above commissary. Please notify EHD if the status of their operating permit changes. www.stancn4ntvcom <br /> STRIVING TOGETHER TO BE THE BEST <br /> REHS Signature "\\\(?.1.1.11„- 2 \hq�pW - Date ��b�� Lb 2 <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 /> S <br />