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Pic0 5ggg0o <br /> SAN 10 A Q U I N Environmental Health Department <br /> ------ COUNTY- <br /> ;; Crreotrume ; yrow be <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> b APPLICANT <br /> Business Name�O S )e-Te_s G q ueyv,-,- Lic. Plate <br /> Owner/Operator Name 1r��1 ' sP Yla <br /> Business Mailing Address x:102 %+ " <br /> City S-kl�C :k03Sttat(CZ2, 'Zipq!5)Q Bus. Ph. 2� G-W'45�(PV' <br /> Alt. Ph. [2-1 tr2 <br /> I, e y\"Q,V�e r JU t 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_ <br /> 1, T1Q`16 doh leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name OMe Y FA# <br /> Address`Zaw l� W Bus. Phone 00^ Lk-o` — <br /> City� 4c�n 0 <br /> Zip Owner/Operator�,�� <br /> Check all appropriate services provided: <br /> 14 Wastewater disposal M�_3-compartment sink Electrical hook-ups <br /> 19 Solid waste disposal ® Food preparation E�Toilet and handwashing <br /> 16 Hot & Cold water for cleaning ® Store refrigerated food Potable water <br /> 0,6Vre dry food/ pplies Overnight parking Vehicle wash <br /> ti <br /> I'CIV <br /> e/LN_1_ _ f�I�Q z— , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and s the California Health &Safety Code requirements. If the food facility <br /> operator f ' o c ply with the co ons of this agreement, or if this agreement is modified or cancelled, the <br /> commis ry own hall notif Y. <br /> ' Date �— <br /> Signatur 1, - <br /> r,rt the ENV HEALTH jurisdiction outside of San Joa uin 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 />