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N 1 (l Q U I N Environmental Health Department <br /> - COU r,1TV-­ <br /> COMMISSARY <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 �. D5 j,9 e,,R t Dj Lic. Plate# 7,626614)-Z <br /> Owner/Operator Name N_ © 5c K. 3240,6919 <br /> Business Mailing Address Y 0,9 Al, 11411' ? �2 55 <br /> City 5'T0(K(dlV State CR ZipV::5- )' Bus. PhCec9.570 -C((3 Alt. Ph. <br /> � <br /> .p <br /> 1,�t Wit-�C k; I b'�C 8 UG R 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 Count Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is sc tinued, the pe i older must notify the EHD. Failure to notify this office may result in permit <br /> evocation an pe aI s. <br /> Signature - Date tJ/� /ZcZ <br /> 2. To be comlSlete_6by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Idlti) ( C)N/ CA r6RI tiG lR ICK CCtiIEP / FA# <br /> Address 717 S tyty �w 5-F. Bus. Phonnqe(ZO)�v-z�d <br /> City ILC jD2ro (,a Zip 7 Owner/Operator /7 I (P h d <br /> Check all appropriate services provided: // <br /> T,'Wastewater disposal V3-compartment sink rD/EElectrical hook-ups <br /> Solid waste disposal VR'F-ood preparation M 1 oilet and handwashing <br /> LG Hot & Cold water for cleaning ;Store refrigerated food �otable water <br /> w/Stooree dry food/su/�plies Overnight parking fL4ehicle wash <br /> I;�1/C`-r�it lfy e, , hereby state that the information I have provided is current, true and <br /> correct to the besi 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 <br /> sNrajl im diately. Qr <br /> Signature �/ Date 20/2 Q 2- <br /> 3. <br /> 3. To be Completed by the ENV HEALTH 'urisdictioh 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 <br /> 9868 F. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 404-0133 1 www sigov.org/ehd <br />