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SKJOAQUIN 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 <br /> leted-by APPLICANT <br /> Business Name-7- C% F_ zG Co C Lic. Plate# t U �;? 87Z <br /> Owner/OperatorName_�Cc� c s�o Ge Yas�wr \ ave z <br /> Business Mailing Address l)- 3 5 <br /> City TC State CZip ! . Bus. Ph.La-U5) 3/%-76 6Y Alt. Ph.� �9/ <br /> y-296 <br /> I, F6ahc5t0 'osrks�rci 1 E, ,4R-"L , 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 /> SignatuEer— Date <br /> 2. To be completed bCOMMISSARY O ER/OPERATOR <br /> Commissary Name/l FA#G� <br /> Address Bus. Phone <br /> CityIt /y- L Zip `j 0 Owned <br /> Check all appropriate services provided: <br /> 10 Wastewater disposal 3-compartment sink Electrical hook-ups <br /> } Solid waste disposal ® Food preparation El Toilet and handwashing <br /> Hot & Cold water for cleaning © Store refrigerated food t6l Potable water <br /> dry food/st��- tes f Overnight parking t Vehicle wash <br /> 1, 1 dOAI/1{/t" / "�plA lyh( C , 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 fail 1s'gomply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa ownor shall.notify the:. D immediately. i <br /> Signatur � C-"),2-I� Dale G "(�'� — L7-0,9.5;4- <br /> 3. <br /> 7-Oc9.5;4 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 IF 209 464-0138 1 www.sigov.org/ehd <br />