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SANsJOAQUIN p <br /> Co Environmental Health Department <br /> —COUNTY— <br /> c, iwr' Greoiness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 To be,.com leted by APPLICANT <br /> Business Name /t t C '61/111-cc- / I s Lic. Plate#-1y <br /> Owner/Operator Name_ M/Moly. Ie,M�EE <br /> Business Mailing Address (' 6 3D3153 <br /> City,2[6: jj2LA4 State41 Zip , ,,2/3 Bus. Ph 2d 6- 8 .33AIt. Ph. <br /> 1, 147 AC U. �J& ��, 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. 7 <br /> Signature t—44 _ 2i1 1 �O Date 142 0 2-2- <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name D 705w1AI ',0 u(k C6fti FA# <br /> Address 171 7 S , UsJtOKI 5T Bus. Phone 207) 6 <br /> Cit y5TQ�kT� (IS, Ch Zip -6v2-OQ Owner/Operator&=if) C7 <br /> Check all appropriate services provided: <br /> Wastewater disposal (46-compartment sink 0 Electrical hook-ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> 0 Hot& Cold water for cleaning 0 Store refrigerated foodtr table water <br /> 0 Stored food/su plies 0 Overnight parking Vehicle wash <br /> I, od I kM D , 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 owners II notify the EHD 'mmediately. <br /> Signature Date o2 /-2 1;202 Z <br /> 3 To be com feted by the ENV HEALTH jurisdiction outside of San Joaquin 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 />