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tY4 <br />SAN JOAQUIN <br />--couNT, <br />v3reatnss grows her . r- <br />Environmental Health Department <br />f)'4D <br />COMMISARY 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 />To be completed by APPLICANT <br />Business Name HIJ1 Ckielese F 0 ea Lic. Plate # <br /> <br />Owner/Operator Name Van 14a <br />Business Mailing Address c( I 2.2. elide re% ss <br />C ity 54-PeAktin State (.A Zip 95 !St Bus. Ph. (2'r) 6.61 -4661 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 Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Pax's <br />Address lau S. re 54ree Bus. Phone (209)33 g-3‘6 3 <br /> <br />1, <br />FA# <br />City /(40423,6 Zip 4535i <br />Check all appropriate services provided: <br />a'Wastewater disposal Eirj-compartment sink <br />DYS—olid waste disposal 0 Food preparation <br />(Zen-at & Cold water for cleaning 0 Store refrigerated food <br />0 Store dry food/supplies CKOvernight parking <br />OK.lectrical hook-ups <br />0<ilet and handwashing <br />E'Potable water <br />re/ehicle wash <br />Owner/Operator tdiiiiais, gerA o i1 z- <br />I, Mark Luis CANA , 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 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in adw,st cuA County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. 4he above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />p <br />RENS Signature <br /> <br /> Date 00 (2-6 <br /> <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I wvvw.sjgov.org/ehd <br />0 s 31-109_