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° . SAN. JOAQUIN Environmental Health Department <br /> r4' . . <br /> —COUNTY— <br /> .1 Greotness grows here. <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 by APPLICANT <br /> Business Name hiQiy'itjo avid mkixaY\ �umk t ! Lic.Plate# 4Uf q(4B2- <br /> Owner/Operator Name Yayta Qy%A t:%X'jci Ciay6ct <br /> Business Mailing Address $43'3 N%wNoryiwCt d CN <br /> City ' �Dbm CbYI State,�_Zip9 7-1 Bus. Ph.(2M) $L]! g4STa Alt. Ph.(' 1013R1-(e4j9 <br /> 1, Y\ci (-wn` o1 , 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 /> Signature—�— Date R1 7-/2OZ,Z <br /> 2. To be com leted;b .COMMISSARY'OWNER/OPERATORl__ <br /> Commissary Name /41101yta r-nm iSOr i4 Mnc/es4-o FA# <br /> Address la it S. 74" Sdvr 4 Bus. Phone C200 338- 36G 3 <br /> City /40des4o Zip 4535+ Owner/Operator 6p/a/ 5"e la,..,..%ssanr. lnc• <br /> Check all appropriate services provided: <br /> M Wastewater disposal p 3-compartment sink le Electrical hook-ups <br /> ® Solid waste disposal ® Food preparation ® Toilet and handwashing <br /> IZ Hot& Cold water for cleaning id Store refrigerated food l8 Potable water <br /> W Store dry food/supplies 3 Overnight parking to Vehicle wash <br /> I, AmL L,jfs -Crw Z , 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 notify the EHD immediately. <br /> Signature ;/'(E�l� Date 0 v2s'l2 a <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa. in Co. <br /> The commissary is located in 56AUSI&kJS C oCounty. The above food facility meets the <br /> commissary requirements in California Health & Safety Code.h above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes, / <br /> REHS Signature W Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />