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PRa5� 113d/ <br /> _ SANsJOAQUIN Environmental Health Department <br /> C O U N T Y <br /> Greatness grovIs here. <br /> Oliver ` Disrriu . <br /> COMMISSARY AGREEMENT jW6jk ==VA <br /> Turlmk CA 95= <br /> Mobile Food Facility • Caterer aW <br /> Complete sections 9 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> . To:be`com leted,b` !APPL'ICANT; '. i <br /> Business Name Ct C'--)S Tci l_5::- Yl Lic. Plate# u �9 916 ^� <br /> Owner/Operator Name �UY� -�'D_IG�' Y!� Z �D <br /> Business JMailing <br /> Address �Jj Z _ u✓1 �, o ce <br /> City c�Q�7 v StateC to Zip 9�Bus. Ph. 7­0 q'6D2- D 161 Alt. Ph. <br /> L C 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 Califomia Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the p rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties <br /> L� <br /> Signature Date_ ' _ 7. Z 2 <br /> 2 ,t%k'WWl W00M_ _M 0-SAN WNE,Rp/O�PERAaT01R` 'r <br /> Commissary Name l JI t U G( e'5 Tif:L' b1lDvl Ltwlni_��W <br /> Address 145 (r" ocy V—C-L- Bus. Phone <br /> City 1 U Y I +y ( Zip � Owner/Operator--TYan,< Z' J 6Eyt <br /> Check all appropriate services provided: <br /> "Wastewater disposal E`3-compartment sink M—Electrical hook-ups <br /> e Solid waste disposal i-Food preparation EF'Toilet and handwashing <br /> EJ Hot & Cold water for cleaning Ef Store refrigerated food EJ_Potable water <br /> Ef Store dry food/sup pli�s,lOvernight parking Vehicle wash <br /> I, '(n��i. f + ► �� 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 EHD immediately. <br /> Signature_ _ Date <br /> 3, To be com leted.,b ,:the:`ENV HEALTH urisdiction:outside'.of-San J.oa uin.Co. <br /> -The commissary is located in The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The a e 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, CaliPornia 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> V <br />