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Pi�os[4 4 � 4`9 <br />SANJOAQUIN Environmental Health Department <br />COUNTY— <br />ii <br />OUNTY— <br />ii hr,,: <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2. Ifyour commissary is located outside of San Joaquin County also complete section 3. <br />1. To be cornfeted b APPLICANT <br />Business Name �raCOS NGyOV IA Lie. PlateiF27uu LAUD <br />Owner/Operator I <br />Business Mailing <br />,36 <br />i, tMUr 1 U YUIU Lv f , 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 oenalfies. <br />2. To be corn` feted*'COMMISSARY OWNERAWERATOR <br />Commissary Name �a ('ami FA# <br />Address_ I -L\\ S- qi" Bus. Phone (,7t?9)79R- 1c63 <br />City MoAeSka Zip q5- 5 Owner/Operatorr��r( <br />Check all appropriate services provided: <br />B'Wastewater disposal 1113/3 -compartment sink E(Electrical hook-ups <br />Solid waste disposal Food preparation EKToilet and handwashing <br />til/Hot & Cold water for cleaning Store refrigerated food dPotable water <br />m Store dry food/supplies dovernight parking M Vehicle wash <br />I, MQ( -V- L t, i 5 (All 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-EHQ-bmmadiateiv. <br />The commissary is located in 5Tp NrS t_q ub <br />wmmissary requirements in California Health & Safety Code. The <br />abovecommissary. Please notify EHD if the status of their operating <br />REHS <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 <br />iV <br />TOMO d <br />3"Whz <br />�tiom��u <br />o c u c <br />o <br />m�O�U�i W <br />6 01 <br />