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SAN JOAQUIN Environmental Health D, nt <br /> COUNTY :,._ <br /> I <br /> !COMMISSARY AGREEMENT " <br /> Mobile Food Facility + Caterer <br /> Complete sections 7 and 2. !f your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name The. Chu rYD S po Lic.Plate# `i KZ OCJS 6 <br /> Owner/Operator Name MUNd d(Xloa <br /> Business Mailing Address S"0CkOWbNI)OK" wel q <br /> City MWOM StateL)9ZipOI�Bus. Alt. Ph. <br /> 1, MicIla eA Ochue , 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 ��� Date_1/31 LAOV q <br /> 7-7 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Za 6.nvn; ei,: /4lo.r/v5h, FA# <br /> Address- 1211 S. :7,4 Bus. Phone Cam 338-3,6c 3 <br /> CityAtrz+' 4s Zip 5535 Owner/Operator( ,f/ .6repo <br /> Check all appropriate services provided: S/Orli r <br /> 0 Wastewater disposal PP 3-compartment sink GI Electrical h 5 <br /> I@ Solid waStg disposal h Food preparation M Toilet and I <br /> 19 Hot&cold water for cleaning M Store refrigerated food 0 Potable wE <br /> At Store dry food/supplies 0 Overnight parking 93 Vehicle wa n/Y <br /> I, ark /moi <br /> CAI-? Senior hereby state that the information I have provided i MARY-KATE COOK <br /> Senior Environmental Health <br /> correctlo 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 /> /�� - 3122.. 3800 Cornucopia Way,Suite C <br /> i �' , DateModesto,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 5/11�u%b`nkn 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 /> w,vw« nco nfv m <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date �I b�I1�'L <br /> STRIVING TOGETHER TO BE THE BE <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 />