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Date (5: `2 • - <br />Jr. SAN JOAQUIN <br />—COUNTY— <br />GrIl-cltnEss ore y.,5 <br />EnvIronmenta Meallth Depailment <br />Nog't0o q\c?" <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 />..b:::be:10.0tilbleted-by•APPWCANT•-• <br />Business Name ro..?1,eyiti cia Za y (J/Q itel-Ajc. Plate # <br />Owner/Operator Name /ha r i iyt() I (-1 e_-, C-1) ci <br />Business Mailing Address I264 A/ 1-1)-:' <br />City Llp 1 State 1.C.,Zip 7e-lk, Bus. Ph. ,96-4 3)3 Jicp/Alt. Ph. <br /> , 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. <br />Signature <br />Commissary Name c("6-•;›,Et ef,—„et <br />Address cr v,e Bus. Phone (?4 V—Pri, <br />Check all appropriate services provided: <br />g47 Wastewater disposal 14:3-compartment sink 4-Electrical hook-ups <br />Solid waste disposal ral Food preparation g Toilet and handwashing <br />la Hot & Cold water for cleaning FZ Store refrigerated food PXPotable water <br />Ell Store dry food/supplies M.- Overnight parking 91,'Vehicle wash <br />., <br /> <br />'(, , ,,,e., L.),,,, ', . 4,-- ?..„, , hereby state that the information I have provided is current true and correct to the -best of MY knowl e, 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 sh.9ofify the EHD immediately. ..-..-_--4,-,--Z. ---."--, _ Signature Date ...-- <br />'n-ibleted by the-E• HEALTHjurisdictidn 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 Stockton, California 952051 T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />FA# <br />City 1,4 Zip c)_02-C76.) Owner/Operator „"9141"