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SAN,JOAQUIN p <br />Q <br />v Environmental Health Department <br />—COUNTY— <br />Greatness 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 com }} leted b APPLICANT I <br />Business Name ' QgIJtrr4 los y i Z� P_'s Lic. Plate # 4 PW <br />Owner/Operator Name Mqu O tro furs <br />Business Mailing Address X164 e. 13 S� <br />City. SA" n StateCA.Zip qs� 66 Bus. Ph( 3A I --At 41a__Alt. Ph(a99) $ 4 44 S 9 <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 penalties. \� <br />Signature Wc.Jr�ya )0 VA -g `PJ' Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name E L arkbov 06 WL; -� e5rvJN FA# 2t L96 <br />Address e --Z--(8 Lb m O\ <br />�PU1 AUG Bus. Phone �lG. 3 Z- 3 g Lit, <br />CityCN�Sc �ALvA+e ip R3�ril Owner/Operator C-ips'tpo-�C- <br />Check all appropriate services provided: <br />Wastewater disposal Jq 3 -compartment sink 1p Electrical hook-ups <br />�J Solid waste disposal 14 Food preparation P Toilet and handwashing <br />® Hot & Cold water for cleaning M Store refrigerated food Hj Potable water <br />431 Storedry food/supplies Overnight parking IP Vehicle wash <br />I, a'-�Nuo (. ' h'r--'ry'..,. , 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 notifytl4y EHD immediately. <br />Sinnahva ____ Hata <br />0. To be compTted by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in _ ��� County. The above food facility meets the <br />commissary requireme in California Health & Safety Code. The above checked services are available at the <br />above commissary. ea a notify EHD if the statu f their operating permit change . <br />�i' <br />REHS Signature._. Date 2-3 <br />1868 E. Hazelton Avenue I Stockton, Cal'do is 05 I T 209 468-3420 I F 209 464-0138 1 www.sjgov.org/ehd <br />e <br />