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SAN JOAQUIN Environmental Health Department <br />— <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 completed byAPPLICANT /� <br />Business Name II AU011YC Ts Ay & /� 61)" Lic. Plate # <br />Owner/Operator Name F/l#�RVKH Z gASR/r/ , SAFF'o <br />Business Mailing Address 7q.Z 9 MAIQGA 14)hV <br />City E2K4S' VC_-Statef_Zip 2OZ Bus. Ph. Ph. <br />I, TayY&.kh 7. lla5hrrrr , 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. h . A <br />Date o2 - X3. 2 0,9—Z <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name LAST tNES t /fiewrFT de t [C FA# 0000560 <br />Address 9 I n S c.H6A_-'okZ-E 6*1v'& Bus. Phone 2-Oq - 62S- RZI If <br />City 1-0t�f Zip CISX-4d Owner/Operator 0 -, Ary, A P-pSFtFD <br />Check all appropriate services provided: <br />J3 Wastewater disposal M 3 -compartment sink 21 Electrical hook-ups <br />® Solid waste disposal ® Food preparation R Toilet and handwashing <br />® Hot & Cold water for cleaning M Store refrigerated food ® Potable water <br />® Store dry food/supplies ® Overnight parking O Vehicle wash <br />I, 103 Am K A ASH F t7 , 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 />commissaryner shall oi theEHD immediately. <br />Signature L A ""`�'� ' "` ' Date 0z 1-73 120 7 Z <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 <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 />