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S A N J QAQ U(N Environmental Health Department <br /> -00U N T Y <br /> o. <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 com leted-by APPLICANT <br /> Business Name C Z-� 0 '5 M 6-A I Cff IV�S EA F6 6 fl Lic. Plate#/Y R5,3 96 <br /> Owner/Operator Name JUSe &rk?�Fda R6fiRIOUCZ f1 A L R <br /> Business Mailing Address 6232y 40016 AR <br /> City.5 1-0( kCTO (y State C�Zip graa 6 Bus. Ph�b`) 557-07.f Alt. Ph. <br /> I,,, o5 - �4rREbire Rc)D9i Guco 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 Date 7 /OZ <br /> _-L7 <br /> 2.,76 beeom feted bY. <br /> �COMMISSARY.OWNER/OPERATUR i <br /> Commissary Name (, 00IV 6f17Ei2110C C-1JT6P FSnA\\# ,�11 <br /> Address 17 I� vim. u4U'(Ol< sr, Bus. Phon <br /> City l�C ]i C-d Zip Owner/Operator / 7 1 k ff6 d <br /> Check all appropriate services provided: <br /> (Wastewater disposal C2/'3-compartment sink i2"Electrical hook-ups <br /> /Solid waste disposal MFood preparation b�Toilet and handwashing <br /> EI/Hot& Cold water for cleaning 4d/Store refrigerated food ��Vehicle <br /> table water <br /> Q/Store dry food/su plies I"Overnight parking wash <br /> I, Il�IRA t (�) -, 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/sh�Il n%o fyth/e HD imm diately. <br /> Signature Date 7/7 <br /> 3. To be com` feted b :the;.ENV HEALTH:'urisdition:ou#sade.oSan Joa ujn.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 <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />