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SANS-MAOUIN Environmental Health Department <br /> --CC)uNTY- <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 /> 1. To be completed by APPLICANT <br /> Business Name (,a;19�&C3 Lic. Plate# 'Mla3'l <br /> LZ <br /> Owner/Operator Name Do"o� 14 5 Ri dandy <br /> Business Mailing Address 3Yo , Dr <br /> City /"(0[(es4o S ate�Zip� Bus. Ph. t2vlr7yf5'-Y 31 Alt. Ph. <br /> 1, L. -t-4- , 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 penalti <br /> Signatui;�;�� Date <br /> 2. To be completed by COW SSA OWNEMPERATOR <br /> Commissary Name Qx5 Kfc4crn 1-4C FA# <br /> Address Bus. Phone td)3311-.364_3 <br /> City Rode 54o Zip 95351 Owner/Operator <br /> Check all appropriate services provided: <br /> �Nastewater disposal 1�3-compartment sink 83""Electrical hook-ups <br /> Ey"'ISolid waste disposal U food preparation Er Toilet and handwashing <br /> eHot& Cold water for cleaning 0 Store refrigerated food C(Potable water <br /> 0 Store dry food/supplies Sr Overnight parking [S Vehicle wash <br /> I, Park Luis C►'71z , 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 no' HD 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 5A6MtS`(I.,I i 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 commissa 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 � F 209 464-0138 1 www.sjgov.org/ehd <br /> ?R 70>1 J_2_ <br />