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SANAAQUIN Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a 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 completed by APPLICANT <br /> Business Name T I IG 11 I Y Lic.Plate# 44 01.5 (..n <br /> Owner/Operator Name Wano nkfa Gy-kc, e <br /> Business Mailing Address—a 1pLQ' bl�o n ; op . --F �4a. <br /> city.Tt Cl(C Statef—NZip�j Bus. Ph. ,�CC1•�LIU -�q q, Alt. <br /> I, M(+l-t C Il jo,a , 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. l <br /> Signature_. ( Cf `r � �(��( Date cllI —I a j <br /> �J <br /> 2. To be com I t b COMMISSARY OWNER/OPERATOR <br /> Commissary Name_L FA# CQZ7 4 3 <br /> Address—V(012� ��}r' lq ^J ' Bus. Phone -20ci - 717 9G, <br /> City. Zip 9. Owner/Operator 5+;P Vt- �t4np <br /> Check all appropriate services provided: <br /> l(Wastewater disposal 0 3-compartment sink Electrical hook-ups <br /> ®JSolid waste disposal ❑ Food preparation Toilet and handwashing <br /> ❑ Hot& Cold water for cleaning 13 Store refrigerated food [;(Potable water <br /> ❑ Store dry food/supplies 0"Overnight parking a Vehicle wash <br /> I,- listo: < `yI� hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledgefand 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 own hall no ify"l a EHD immediately. <br /> Signature Date 7 2 <br /> 3. To b com leted b the ENV HEALTH jurisdiction 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 j www.sjgov.org/ehd <br /> / C ; <br /> z5m,�, i�}��iY.SS � L' ' [�C C��['CI U'/ a Il1Cl1 � e �C)iYt <br />