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Environmental Health DepartmentIJ <br />,Uc. Plate # '8'^ () 3 ? Q <br />SAN JOAQUIN <br />--- COUNTv --- <br />Greatn/’sj ’ <-r<- <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www sjgov org/ehd <br />FKOSMv* M3 <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 7 and 2. If your commissary is localBd outside ofSan Joaqu jn sectjon 3 <br />I 1 - To be completed by APPLICANT <br />BusinessNameTAfAS OKS IS Tb^TUEl r:. <br />Owner/OperatorName S IJ7-KR STH H1S^-N/ANDr7 <br />Business Mailing Address I 5? i K H TEMPLE ST' <br /> <br /> <br />c^^Mg^stateCA.zip£iS2/)kBus. Ptlzoqxs i-Wah pp._________ <br />f u LU HLF-MN^Rgeby state that the above information is current, true and correct to <br />Safeto Code ?e ®9reeJ° utilize "V aPProved “emissary in accordance with California Health & <br />commiqcsarv L h « County Env,ronmental Health Department (EHD) requirements. If the use of the <br />ZEX perTnrt holder must now tt,e EHD-Faihjre to noti,y this office may result in permit <br /> Signature ££17,..k,.lh Date j 0 | TCTS <br />2. To be completed by COMMISSARY OWNER/OPERATOR ------- <br />Commissary Name\)|'| |LP TfVCKin^ C.IMT1 <br />AddressHn. $■ 'U N10 N 5V J Bus PhonZTZO^I ) ' 5 //J <br />City.STDCKT7)IV__Zip Owner/Ouerator P-fjS I /V I _____ <br />Check all appropriate services provided: '' 0 N i (rj ° <br />Wastewater disposal y 3-compartment sink —Electrical hook-ups <br />Z| Solid waste disposal X Food preparation Toilet and handwashing <br />)s. Hot & Cold water for cleaning yC Store refrigerated food V Potable water <br />A Store dry food/supplies Overnight parking Vehicle wash <br />1 ■ —7 --------------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 withfarrconditions of this agreement, or if this agreement is modified or cancelled the <br />commissary ownCT^balljag^ffie^EHD immediately. <br /> <br />Signature.^^^^^______ ____________________Date Q3 / 0 Ip | Q-f) 7-5 <br />3. To be 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. <br />REHS Signature.Date