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S Q N = 0 Q Q N Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ® Caterer <br /> Complete sections 9 and If your commissary is located outside of San JoaqZf <br /> e section 3. <br /> 1. To be com lete APPLICANT _Business Name D �S A - M0RE gWADIS 4 T-A -LLCOwner/Operator Name MUIZ l-i M oHAIN &' RA.TAN <br /> Business Mailing Address 5 P-(::N D RA-,�0 S-T RC— T <br /> City M A NT&C Pt State_l�Zip q 533`� Bus. Ph.q2 5 58 7 f Ait. Ph. 4 I'2 -716 060q <br /> A' hereby state that the a ve information is current,true and correct to <br /> the best of my knowledge and agree to utili a my approved com ssary in accordance with California Health & <br /> Safety Code, and San Joaquin County Enviro mental Health De artment (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit holder m notify the E Failure to notify this office may result in permit <br /> revocation and penalties <br /> Signature Date 2 <br /> 4 <br /> 2. To.be com feted by COMMISSARY NE OPERATOR <br /> Commissary Name �.IGf G (� FA# <br /> Address // s. Phone <br /> City Lo clrl Zip Owner/Opera <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation ''Toilet and handwashing <br /> .''Hot& Cold water for cleaning 13 Store refrigerated food 't'Potable water <br /> 13 Store dry food/supplies 11COvernight parking Vehicle wash <br /> I, A , hereby state that the information I hav rovided is current, true and <br /> correct to the best of my know) e,and meets the California Health&Safety Code requ ements. If the food facility <br /> operator fails to comply wit the conditions of this agreement, or if this agreement is m dified or cancelled, the <br /> commissary owner shall no fy the EHD imm iately. <br /> Signature Date <br /> 3 To be.com I ted b: the EN ALTH-jurisdictianeouts tle of San Joa uln 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 />