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SAN;JOAQUIN Environmental Health Department <br /> --COUNTY <br /> .: <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3- <br /> 1. To be completed by APPLICANT <br /> Business Name SC-00RS Lic.Plate# <br /> Owner/Operator Name 2 OtJ SHA)) <br /> Business Mailing Address ) � 3$q 6o N 1=-'A RZ, <br /> City leakbmI e state—C14 zip Sq 361 Bus. Ph./.21'?) '195-IS00 Alt. Ph. <br /> I, i�?op 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 enalties. Pts <br /> Signature C=✓, _ Date 6 -ay-,:;?0.W <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name _B(A5�4n kAWgklry_ � FA# <br /> Address 20010 (261C+-hu -PSqC4UAe, Bus. Phone �t0c) • 561612-U.3+ <br /> City zip__a'220 520 41:` Owner/Operator K-va-i <br /> Check all appropriate services provided <br /> [3Wastewater disposal W/3-compartment sink &(Electrical hook-ups <br /> ❑ 'olid waste disposal 21 Food preparation 13�Toilet and handwashing <br /> la Hot& Cold water for cleaning Ed Store refrigerated food Cd Potable water <br /> Store""dry food/supplies p Overnight parking O Vehicle wash <br /> I, k4a-4S \_iWPRJ] j 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 shall) nnotpifypthe <br /> /EHD immediately. . <br /> Signature Date 41 it 122— <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joan 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 4683420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />