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°zA SAN ;JOAQUIN Environmental Health Department <br />I-4'i—COUNTY— <br />�1;,;; r° Greotness grows 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 <br />APPLICANT <br />� 3 Trutilc <br />Business Name fi Lic. Plate # 7 k Ta AS A9 <br />Owner/Operator Name f-1 r} R�) ; a/, G fi ✓a f4 <br />Business Mailing Address 5 66 O 2 DR ��� 1 Z 1 <br />City. :Iv G9 le /C/ State C' b Zip 4c__� ;r,,__Bus. Ph. ,y 114,53 -213D 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 andpenal ies. <br />Signature '41 arct ao q MQ t1 Date a20 � <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name .9 R T rl )RM a S S 1 0-1 FA# <br />Address 311 L mi, 1v b 1;? 6 U � Bus_ Phone :�-ct-- GVNr- 1"7 W 4 <br />city. S �I� � a /�l Zip ! CL Owner/Operator <br />Check all appropriate services provided: <br />p Wastewater disposal ❑ 3 -compartment sink ItYLlectrical hook-ups N <br />W <br />❑ Solid waste disposal ❑ Food preparationoilet and handwashing 0 .16 ;K <br />❑ Hot & Cold water for cleaning M.-8tore refrigerated food O Potable water 0 m Z <br />E3 Store dry food/supplies Qy6vernight parking O Vehicle wash q ' 6i <br />030 <br />I, hereby state that the information I have provided is current, true and Z Z (i <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility 0 m m <br />; <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the > <br />0 <br />commissary owner shall notify the EHD immediately. > 0 <br />m <br />Signature _fir%i-,w .., 04 Date m D <br />3. To be completed by the ENV HEALTH iurisdiction outside of San Joaquin 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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 4683420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />?4h''i'10 1 1 P�2o531014 t FK,05'� 2k] 5 <br />