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SAN JOAQUIN Environmental Health Department <br /> COUNTY----- <br /> ®liv Disi<i�rssa I <br /> Co �ary <br /> COMMISSARY AGREEMENT 14 1KCoy Rd <br /> A 95391 <br /> 53 1 <br /> Turloc <br /> r.� <br /> �. Mobile Food Facility s Caterer 2,09=634-2000 <br /> Complete sections 1 and 2 N your commissary is located outside of San Joaquin County also complete section 3. <br /> .APPLICANT .,a -- <br /> Business Name e A how Lic.Plate#�� <br /> Owner/Operator Name <br /> Business Mailing Address -� Yt�l� � T�y <br /> City sm Statejfo-Zip Bus, Ph.2c`\ 4AT Alt. Ph. <br /> 1, >1L4C- c go.�� 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 /> Signatur —,. J A " Date n� I -7 2�Z� <br /> 2. To be completed by COMMISSARY OWN EMOPERATOR <br /> C <br /> Commissary Name ��d5�� �h �mm�SOFA# <br /> Address_1(15 'j . L if oc, ej . Bus. Phone 7, c/' ZX7 <br /> City I w✓ 1.0 C,�i Zip a jj', 6D Owner/Operator r;,' -je <br /> Check all appropriate services provided: <br /> p'Wastewater disposal 0"3-compartment sink Electrical hook-ups <br /> Solid waste disposal 12rFood preparation $Toilet and handwashing <br /> 2Hot& Cold water for cleaning ,Store refrigerated food Wpotable water <br /> O'Store dry food/sup lies Ef-Ovemight parking C Vehicle wash <br /> I, E' C1 /mil 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 immediately. <br /> Signature Date -1 7- ?,0 Z5 <br /> W*W6ted#y the ENV-HEALTH `urisdidtion 6i tsirie.of San J' u(n .Gt�k <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. Califomia 952051 T 209 468-3420 1 1= 209 464-0138 1 vnvw-sjgov.orglehd <br /> ----------------------------- <br /> Scanned with <br /> CamScanner <br /> 25 0)ZQ'T ----------- <br />