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SAN 10AQUIN a <br /> Environmental Health Department <br /> -- COUNTY-- <br /> E; �QO S`3 0 reotn�ss grows 2 <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 b APPLICANT <br /> b <br /> Business Name H N (�iAese rood Lic. Plate# <br /> Owner/Operator Name _rydn A. <br /> Business Mailing Address q 1 ZZ t31ve 4rass <br /> City State_(,&_Zip 9S SSA Bus. Ph. (24Q) (o%j -9G6( Alt. Ph. <br /> I, , 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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name /uaxS ki l che-n L LC- FA# <br /> Address (atti S T", Scree- Bus. Phone (200 3 3 S'34C3 <br /> City /-4oje.%4, Zip g535i Owner/Operator Williap% /,3er/iow%fgL <br /> Check all appropriate services provided: <br /> (Wastewater disposal M"'3--compartment sink electrical hook-ups <br /> [a--S_olid waste disposal 0 Food preparation Toilet and handwashing <br /> OTot & Cold water for cleaning 0 Store refrigerated food H"Potable water <br /> 0 Store dry food/supplies L31"Overnight parking W"V'ehicle wash <br /> I, Mock LV1 s &'VI , 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 notify the EHD immediately. <br /> Signature Date 14-25- <br /> 3. To be completed by the ENV HEALTH <br /> ' Jurisdiction outside of San Joaquin <br /> t Co. <br /> The commissary is located in ' j_k Qj 6U W County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. e above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> c <br /> REHS Signature Date_��(p7 <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 /> PC 0S31-1o�2_ <br />