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SAN�JOAQUIN Department <br /> Environmental Health De <br /> " t:eM ,• <br /> ` —COUNTY— <br /> Greatness <br /> —COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility♦ Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be cam Meted b APPLICAI NT I 1 <br /> Business Name Lic.Plate# <br /> r <br /> Owner/Operator Name Ty7lV1A5C•D IP[AVLS COOWiAS <br /> -Business Mailing Address ?D P)( I <br /> city 511�tstate zip q 5 Q 9Bus. Ph.'LV'1 ( 31�C Alt. Ph. 211 <br /> l,Wd1V1C KuD 1(f1 eno s C 6 h h4+'A thereby 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 andities 9 <br /> Signature Date <br /> 2. To be com .aeted by COMMISSARY.OWNERfOPERATO <br /> Commissary Name G l (I lru! ((I hu i NG FA# <br /> Address., ,IAO,d_t' j") . L'0A5yrtW Bus. Phone 2-00l'00i�"I� 1 — 3 <br /> , j �1� <br /> City `>r'�v Zip �5� OwnerlOperatorFYMOSCO 11AWIS C(LIJ'Y' -e7kS <br /> Check all appropriate services provided: <br /> d Wastewater disposal Ef 3-compartment sink Cf Electrical hook-ups <br /> of Solid waste disposal [(Food preparation G(Toilet and handwashing <br /> 14 Hot& Cold water for cleaning 0 Store refrigerated food K Potable water <br /> e Store dry food/supplies /� Cr Overnight parking C(Vehicle wash <br /> 1,f r ICl SC 0 ((ct iv IA13 N W3 , 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 o r sh II n/otify EHD immediately. r J <br /> Signature_��'F Date l� —� <br /> 3: To be com Meted'b the ENV HEALTH 'urisdict of n`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 Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />