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SAN. JOAQUIN Environmental Health Department <br /> ! ' —COUNTY— <br /> e� Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t 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 APPLICANTi:., <br /> Business Name Lic. Plate# 7 i 6) <br /> Owner/Operator Name /^aiA;� M /1nl �V, l -� I tK <br /> Business Mailing Address 5- 056 0 F iq f-j� R U 5-2 'DR &_27 1 Z t <br /> City S'fe al"Al State_,<e Zip 4c�Bus. Ph.)v +493 ^,�?1f 3g Alt. Ph. <br /> I, ,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 penal les. <br /> r <br /> Signet z & q %ICI11 Date * / 020 <br /> 2. To be completed b COMMISSARY OWNER/®PKRA 0R. ; <br /> Commissary Name 9 A%n1 ft S S 9 in-7 FA# <br /> Address- 3-1)Z r4l,ry t R F4 U k Bus. Phone -G- GMlr- 1'7 w 4 <br /> City S ivSfJ( 1 D/�� Zip CA_ Owner/Operator <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal 0 3-compartment sink D Electrical hook-ups N <br /> 0 Solid waste disposal 0 Food preparation oilet and handwashing 0 � x <br /> 0 Hot & Cold water for cleaning 0-5tore refrigerated food 0 Potable water n N Z <br /> E3 Store dry food/supplies gKvernight parking 0 Vehicle wash I m C) <br /> 03 <br /> I hereby state that the information I have provided is current, true and Z Z O <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility 0 M m <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the D x <br /> commissary owner shall notify the EHD immediately. tp D 0 <br /> Signature � . �,'J, ` fQ ' ..Date__LL—/— p m D <br /> Cn � <br /> 3. To be corn leted,b the ENV HEALTH 'urisdiction..outsideof.San,Joa uin Co. <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />