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- SAN IOAQUIN Environmental Health Department , <br /> COUNTY — <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 b APPLICANT <br /> Business Name TAI AN EXPRESS PAS01 IV( Lic. Plate# (J68gO59 <br /> Owner/Operator Name POORkN SIN (H H <br /> Business Mailing Address 101-{ 3Z _fY IZ E D R — <br /> city ,STN State LP Zip 10Bus. Ph. Zpc{-�Z``�4��It. Ph. <br /> 1,_ PoakhN S I NL H 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. f^ �O n <br /> Signature , d�/�✓/ 2t Date 0:5 `� f -C <br /> 2. To be com leted b' COMMISSARY OWNER/OPERATOR :>. ._ <br /> Commissary Name 4 _ FA# <br /> Address _Bus. Phone t ' <br /> City L ZipOwner/Operator e <br /> Check all appropriate services provided: <br /> IX Wastewater disposal O 3-compartment sink I�YElectrical hook-ups <br /> 1p Solid waste disposal I7 Food preparation I Toilet and handwashing <br /> 10 Hot & Cold water for cleaning 12f Store refrigerated food Potable water <br /> 0 Store dry fogd/su plies Overnight parking f Vehicle wash <br /> 1 hereby state that the information I have provided is current, true and <br /> correct to the best of my ledge, 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 tify t E mediately. 1199 <br /> Signature Date <br /> 3. To be corn 'feted b ENV HEALTH 6Sd!etion otatsrde,o - <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. Hazefton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br />