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SAN$JOAQUIN Department <br />Environmental Health De <br />" r;"t<<' —COU NTY— <br />�,,, Greatness grows here. <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 />1. To be completed <br />by <br />APPLICANT <br />Business Name —TcIy <br />V 0e, <br />; c� ��r M'. v �� <br />/ / <br />Lic. Plate # �-1 VA 3354 <br />Owner/Operator <br />Business Mailing <br />Cit�c State h Zip9 S%_-�t Bus. Ph. Alt. <br />I, m r %Z" 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 :2 �-�� Date <br />2. To be completed -by COMMISSARY// OWNER/OPERATOR <br />CommissaryName 1 6am/5nrle M.OA49 FA# <br />Address 1211 5_1""" 'S� Bus. Phone (IQO)335-3�4-2 <br />City /4Onbrzs-in Zip gS35I Owner/Operator V_/v� ,, '5.s�,lsr. <br />Check all appropriate services provided: <br />!Q Wastewater disposal P 3 -compartment sink JU Electrical hook-ups <br />pt Solid waste disposal 93 Food preparation U Toilet and handwashing <br />IX Hot & Coldwater for cleaning 0 Store refrigerated food )3 Potable water <br />13 Store dry food/supplies P Overnight parking J0 Vehicle wash <br />I, /jark to i 5 Cs^y, , hereby state that the information I have provided is current, true and <br />correct fo 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 �A_V int - Date // C23 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin <br />The commissary is located in 00 -cvn lS t0 U J 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 Sianatule Date 11 / o 3 _1 2c, <br />J • � � ��E-Ili �k 9�y� <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 lwww.sjgov.org/ehd <br />00 <br />