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7,2() Su _�_j2Z <br /> SANJOAQUIN Environmental Heafth Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility .., Caterer <br /> Complete sections 9 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 1ra N te Lic. Plate# L-1 T U 3 14(o <br /> Owner/Operator Name r_6 i r1 (7 CZurc'+ CA <br /> Business Mailing Address �� � .Z U �-o Pt S <br /> City 6�pCk�ar\. State Zip SZ Bus. Ph. Alt. Ph. 20 5 <br /> 1 ern; rC i A 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 _ �� i s Date 2_S <br /> 1.2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name) tc4 Co ren e-Y-6 OL t �p� rc�'t c vim+ FA# <br /> Address '--c4 0 0 5 kjA Bus. Phoneµ 2d ct6 g rYs�Z D <br /> CityT Sc �°V` _Zip 957-05 Owner/Operator_ Cry e• �'G �'er�e-�'" <br /> Check all appropriate services provided: <br /> - -Wastewater disposal q5,3-compartment sink c>< Electrical hook-ups <br /> -olid waste disposal I A Food preparation `Toilet and handwashing <br /> Uot & Cold water for cleaning [2 Store refrigerated food -<Potable water <br /> lJ Store dry foodlsupplies Overnight parking a�,/j Vehicle wash <br /> �CC�riCL�, hereby state that the information l 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 n tify the EHD immediately. Q� <br /> Signature Date <br /> 3. To be com leted b the ENV HEALTH jurisdiction outside of San Joaquin 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 /> Date <br /> RENS Signature <br /> 1868 E. Hazelton Avenue I Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0) 38 t �, vw.sjgov.org.ehd <br />