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SANADA UI N <br /> Q Environmental Health Depgtrnent <br /> " 1 k4 " COUNTY <br /> Greotne55 grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 and 2. !f your commissary is located outside of San Joaquin County also complete section 3. <br /> 9. To,be,com a l0b9db APPLICANT ` <br /> Business NamRu t i-s Lic. Plate# VC517 <br /> Owner/Operator Name MT (�lq PU Lb <br /> Business Mailing Address 330 S , SIERRA Nr6U 0 <br /> City-570CK-0(0, State CA Zip?SoZQS Bus. Ph6 is 06664777 z Alt. Ph. <br /> I,8 f R66d A446L b , 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. Z02-2-i1 <br /> Signature Date_- <br /> .2. To be c6m leted by COMMISSARY OWNEW0..PE_RATORI - <br /> CommissaryNameUNfOPJ dO 1_i5WO6 TRie[k(_ tS�C,-FA# <br /> Address 17(7 �S{ , all f/6 yd S 7` Bus. Phone�'4'?I$ <br /> Citys/c7L k�M CA Zip 9,5 266 Owner/Operator /I l 1 I k}b b <br /> Check all appropriate services provided: <br /> � JVastewater disposal 0 3-compartment sink 0 Electrical hook-ups <br /> CWSolid waste disposal 0 Food preparation CQ�Toilet and handwashing <br /> 0 Hot & Cold water for cleaning 0 Store refrigerated food (9/Potable water <br /> 0 Store <br /> food/supplies 0 Overnight parking 0 Vehicle wash <br /> I,•/.It Crr -77r ai)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 owner hall notifohe EHD immediately. PEQ I i <br /> Signature _ /_/ Date "`'` <br /> 3.:To be com l6t6d by the ENV'HEALTH jdrisdic#ion outside of 8p. n:Jog 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 /> RENS 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 />