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m <br />Date <br />Date <br />3. To <br />REHS Signature.Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br /> Store refrigerated food <br /> Overnight parking <br />Environmental Health DepartmentSAN JOAQUIN <br />COUNTY <br />__Lie. Plate# W M5K35 <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 />T To be completed by APPLICANT ~ <br />Business Name 0> 2- C \ T <br />Owner/Operator NameO IM61H H A P- N 0 Q __ <br />Business Mailing Address H~"l I 4 V\| | f\( ]y> Ol\l CT <br />Cityff-hCV StateCKzip^lSus. PhC^SI? Ah <br />th h —P P r~ (JU r—, 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<DSna|ties. <br />Signature,/^^^ Date Q3 j 2/) j <br />n2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Uh/lDN 60 M C fVTF^- <br />Address. Tri S ONION ST _Bus. PhoneTZO^I 2^ - 5Q I (J <br />City Zip T2 0 U Owner/Operator T 0 Si T- f~ N V "0 P 0 <br />Check all appropriate services provided: \/\/ N C/ <br />^LWastewater disposal 3-compartment sink D J Electrical hook-ups <br />^3- Solid waste disposal Food preparation Toilet and handwashing <br />Hot & Cold water for cleaning Store refrigerated food Potable water <br /> Store dry food/supplies Overnight parking ^Vehicle wash <br />*> —-LW I Nn n , 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 cgmptjrwithT^^^^tions of this agreement, or if this agreement is modified or cancelled, the <br />commissary immediately. \ . <br />Signature Date 03 /T/) (701.5 <br />completed by 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.