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SAN f 0 A Q U f N Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ;� Caterer <br /> Compleie sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> �I <br /> Business Name, CO-5 6-L �6�7_011j Lic. Plate# <br /> Owner/Operator Name R M A MU CAST L LC) R'f In l iQ,LCz <br /> Business Mailing Address /33 5 c-AkkaL tit/, <br /> City.5TLkt9/1� State C/- Zip Q�5 Bus. Ph O It. Ph. <br /> I,_#Un4 0J(#j9 irAs Ti t-LO , 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 2 G a- 2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name U fill 4/(J �TC�OI G 21111 k '6""'F` <br /> Address17/75r yr'T Bus. Phone <br /> City_D(,k-rO214 G/Q Zip 95� /v Owner/Operator Aer <br /> Check all appropriate services provided: <br /> I"Wastewater disposal 2/3-compartment sink electrical hook-ups <br /> Solid waste disposal rood preparation ;Toilet and handwashing <br /> EP'H'ot&Cold water for cleaning MO-Store refrigerated food Potable water <br /> `Store dry food/su lieesr� ! Ovemight parking ✓Vehicle wash <br /> I, � 11 /6 / a , 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 sh oti the EHD iediately. <br /> Signature_� ` Date /Z)Z 2- <br /> 3. <br /> 3. To be completed 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />