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SANG:J.UAWN Environmental Health Department <br />—COUNTY— <br />COMMISSARY <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 />Business Name ZIT Q1Q4/5 G��C'V6A1?q MO(cA44 Lic.Plate#WSZ:Z�.39 <br />Owner/Operator NameJ-ttiIy QAUXxEeA 4- jSf1/� <br />'j'Stl,>4-Z4PL <br />?194 <br />Business Mailing Address _ 7 Q 4 S= C C' 0'' 10C1 c 'v <br />City.''(OcM State CA Zip ,y,? S Bus. Ph.(26.0 %I'l-eYS 73 Alt. Ph. <br />I C(Yk"' . 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-laenalties. a <br />---- <br />12-. To be coni leted�b COMMISSARY OWN ERWERATOR, <br />CommissaryName %((l l f G C-? (C- P l hj Cr (RU Ck L6%l FA// FA <br />Address -17/—/,S. U ltfio f-1 F . Bus_ Phone& <br />all appropriate services provided: <br />O/Wastewater disposal O -compartment sink a Electrical hook-ups <br />r0 Solid waste disposal Ellood preparation M Toilet and handwashing <br />i'Hot & Cold water for cleaning Er'Store refrigerated food M-P-otable water <br />E Store dry food/supplies 13-6vemight parking t� Vehide wash <br />/y <br />I, r7— 11-e � 0 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 fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary ownVPh01lkotijy the, EHD immediately. <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 />