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SAN )O AQ U I N Environmental Health Department <br /> COUNTY <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 completed by APPLICANT <br /> Business Name M D M 0 &- jf e tbak) L L L Lic. Plate#-T—Ts—0 T .& <br /> Owner/Operator Name 9 H)qt y=1 A- `tFy" PF- <br /> Business Mailing Address 90/ /\1 • S S kM <br /> City MOUjw�l1 k6WStateL)q ZipBus. Ph. �5 10—q4-5-021XIt. Ph. Z:So �-- <br /> I, Sk/V",K-- OF `fV'?gP 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 penalti <br /> Signature Date SVL'Z, <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> _ s.va A.C1 F <br /> Commissary Name SXYL( TKANsfX)P- I �3 IZy PAU- FA# n <br /> Address q1 3( )MDUS214L �,1)�]` Bus. Phone <br /> Cit i���`7� Zi ' <br /> y � p Q S 3 GLf Owner/Operator PA It-µ11y D ER 61H(7 <br /> Check all appropriate services provided: 4� <br /> Wastewater disposal E3 3-compartment sink Electrical hook-ups <br /> pSolid waste disposal EI Food preparation EI Toilet and handwashing <br /> © Hot & Cold water for cleaning EI Store refrigerated food �� Potable water <br /> O Store dry food/supplies Overnight parking %, Vehicle wash, <br /> I, ft- µ189E 1L 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 w' the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner sha fy the EHD immediately. <br /> Signature Date <br /> �7 y <br /> [-3.1-o be completed 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 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 />