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SANAAOUIN Environmental Health Department <br /> —COU NTY— <br /> Grentness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility• Caterer <br /> Complete sections t and 2. If your commissary Is located outside of San Joaquin County also complete section 3. <br /> 1 To be completed by APPLICANT <br /> TQeos�r uA BULGE Lic.Plate# <br /> Business Name ✓.� �y. .r�+ <br /> Owner/Operator Name -1.1� Se t��S u 69.Rn'5 �1k <br /> Business Mailing Address I,& <br /> city �LjrStati��Zip9orBus.Ph7�l�y7-��',gAlt.Ph. <br /> f rf6 rf hereby stale 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. )� 1'L' L` Date ©�7 D • <br /> Signatur- 05� (K Vi 5 ri el <br /> 2. To be completed by COMMISSARY OWNEWOPERATOR <br /> Commissary Name LComeY'c t u` Gur FA# <br /> Lt, <br /> Address 2�i0 <br /> Bus.Phone 20 1 — Ll o4�S-713 <br /> city <br /> S}-aGk•t}a� Zip C152o S Owner/Operator G �G\4f' <br /> Check all appropriate services provided: <br /> Wastewater disposal M3-compartment sink Electrical hook-ups <br /> Solid waste disposal 13 Food preparation FL Toilet and handwashing <br /> Hot&Cold water for cleaning O Store refrigerated food Potable water <br /> E3 Store dry food/supplies �Overnight parking �Vehicle wash <br /> I, A G1 8G rCRj1W ,hereby state that the information I have provided is current,true and <br /> correct to the be-'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 9etify the EHD immediately. ,�f2 1 2 <br /> Signature Date —I// }— <br /> To be',compled 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 Dale <br /> 1868 E.Hazelton Avenue I Stockton,Califomia 952051 T 209 468-34201 f 209 464-0138 1 www.sjgov.orglehd <br /> f <br /> t�•�t 4 5-� <br /> It��- <br />