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SAN JOAQUIN Environmental Health Department <br /> —COU NTY— <br /> Vr[a hid:s �iowi ilei c. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • caterer <br /> Complete sections t and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name dn <br /> Lic. Plate# <br /> z9 15 <br /> Owner/Operator Name _:\VdC Mxn3 <br /> Business Mailing Address 411420 CoKkao <br /> Rmd <br /> city StateC�LZip %S71P Bus. Ph.(51105U-922=�Alt. Ph. <br /> I, Je,St1S -�\em 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. y - <br /> Signature —YnY�WI Date <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 )¢l Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food gh Potable water <br /> ❑ Store dry food/supplies ® 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 not HD�ately. <br /> bL� <br /> Signature Date <br /> 111112 <br /> j&UU.jQfJ Q wquti law <br /> e . <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 F 209 464-0138 1 www.sjgov.orglehd <br />