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r <br /> SAN JOAQUIN Environmental Health Department <br /> --COU NTY APPROVED <br /> Greatness grCtiv- nrr*. <br /> STAMSLAUS CO. DEPT. OF <br /> COMMISSARY AGREEMENENVIRONMENTAL RESOURCES <br /> � �1a3 <br /> Mobile Food Facility ♦ Caterer gyp•-•-•------kms•-......... <br /> 1 B <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin C - -'-' <br /> 1 . To be completed by APPLICANT <br /> Business Name&adz,, V/, 4 �G¢/id/. rm1n1),_- Lic. Plate# yu T A57 7 <br /> Owner/Operator Names 76&Aef 4,, <br /> Business Mailing Address <br /> City Wi/ C4t State(�t Zip 33 Bus. Phaej'? 6/'13(22- Alt. P 67�U/5- O2/z,�? <br /> I, SP//Yfi fGs� rndwir , hereby state that the above information is current, true and correct to <br /> the best of my knowlec3ge 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 ties. ,q G <br /> Signature Date (/D 'Z'3 � 7iCl7iZ <br /> 2. obe com leted b�+ COMMISSARY OWNER/OPERATOR <br /> CommissaryName Za t omi54rict /-4na(eS4-0 FA# <br /> Address 121) 5. 7+" Bus. Phone 0061) 3315-3663 <br /> City P&J' e.sl-o Zip x5351 Owner/Operator Cold 54D2qe <br /> Check all appropriate services provided: <br /> 12 Wastewater disposal IN 3-compartment sink ® Electrical hook-ups <br /> ® Solid waste disposal M Food preparation ® Toilet and handwashing <br /> ® Hot & Cold water for cleaning ® Store refrigerated food 19 Potable water <br /> M Store dry food/supplies M Overnight parking M Vehicle <br /> I, Mork suis-Crve , hereby state that the information I have provide <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requiremen ' <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modifi <br /> commissary owner shall notify the EHD immediately. <br /> Signature Date OJy <br /> MARY-KATE COOK <br /> 3. To be completed by the ENV HEALTH jurisdiction outside Of Sa Senior Environmental Health <br /> Specialist <br /> The commissary is located In tIrttWt9t.AuS County. The above foc ENVIRONMENTAL RESOURCES <br /> commissary requirements in California Health & Safety Code. The above checked services Environmental Health Division <br /> above commissary. Please notify EHD if the status of their operating permit changes. 3800 cornucopia way,suite C <br /> � <br /> Modesto,CA 95358-9494 <br /> ]�\/�\Y� <br /> REHS Signature , r 4A Q zsz R Date 2C22 Direct:(209)525-6713 <br /> Main:(209)525-6700 <br /> Cell:(209)505-7388 <br /> Fax:(209)525-6774 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 Email:mkcookro7)envres.ora <br /> Nm^.v.stancou ntv.com <br />