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SAN JOAQUIN Environmental Health Department <br /> L —COUNTY-- <br /> Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Complete sections t and 2. it your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> DD <br /> Business Name lF \YlLic. Plate# <br /> Owner/Operator Name L 1S -RxVk(1' MQr-kln��, <br /> Business Mailing Address 4ILep CAt-G ^(ACj <br /> city i01&4 StateCN zip.%S-71P Bus. Ph.(510 5U.g223 Alt. Ph. <br /> I, 6'eSUS -�"�vU S 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. n <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Marathon Gas Station FA# <br /> Address 950 W 11th St. Bus. Phone 209-207-9000 <br /> City Tracy zip 95376 Owner/Operator Mohammad Fayzi <br /> Check all appropriate services provided: <br /> Wastewater disposal ® 3-compartment sink ❑ Electrical hook-ups <br /> ® Solid waste disposal ❑ Food preparation X1 Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food 0 Potable water <br /> ❑ Store dry food/supplies M Overnight parking ❑ Vehicle wash <br /> Mohammad Fayzi , 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 /> �Z 1�5� Date X22 <br /> Signature- <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health 8 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 F 209 464-0138 1 www.sigov,org/ehd <br />