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C. <br /> SANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> L" Greatness grov.s here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ 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;'corn leted by APPLICANT <br /> Business Name 71 IS 6 )U w m DS Lic.Plate#3"�016 <br /> Owner/Operator Name TOS'e Fl6UI ICv o <br /> — <br /> BusinessMailingAddress %0z- S. CcnTrGt -A"v- <br /> City Lod i State Ch Zip '152nD Bus. Ph. 2013_ 119 Alt. Ph.20Ti`_83 <br /> I, U Q PtG V I tIt Y_o`_ 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 isiscontinued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p nalties. Date 1t I1)0I27- <br /> Signature <br /> —Z. T6'64 leted ti" 'COMMISSARY OWNER/OPERATOB: <br /> Commissary Name�� � oy) LZ`/8'339 <br /> Address �20 C �^T" �I Bus. Phone <br /> City <br /> 1(jp i Zip q52 jG Owner/Operator �1r i�r/✓' <br /> Check all appropriate services provide-/d: <br /> QV/astewater disposal / <br /> 12/3-compartment sink ER Electrical hook-ups92/SER/Food <br /> Food preparation Cl/Toilet and handwashing <br /> olid waste disposal p p <br /> Eff/Hot& Cold water for cleaning RStore refrigerated food LY"Potable water <br /> [j( Store dry food/supplies <br /> [2/Overnight parking 0 Vehicle wash <br /> I, <br /> M 74-e ,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 toner m Pll I with the <br /> ty the EHD immediately. <br /> o i this agreement, or if this agreement is modified or cancelled, the <br /> commissary <br /> Date <br /> Signature <br /> 3 T be com l-ted by the ENV HEALTH.'udsdiction outside of.San Joa Lin Co. <br /> tY. The above food facility meets the <br /> The commissary is located in Coun <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.sjgov.orglehd <br /> Scanned with CamScanner <br />