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Ar <br /> S A NsJ O AQ U I N Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <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 com leted by APPLICANT <br /> Business Name L D MC(f€A n" H I D A L ISt) Lic. Plate# 8P9-310-3 <br /> Owner/Operator Name MA 6% Pl1 _� 6 M �d,_1 1!jD 74ff ell L6 I l <br /> Business Mailing Address 9 b 2I!� �� W, <br /> City,�c State�Zip H-45 Bus. Ph[ZO23�Alt. Ph. <br /> 1, X&�W 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. (� l <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name &[&AJ efl T 1AfG 4&9 (4_&176AFA# <br /> Address—( 7 11�5. I/IN)(t 6 Bus. Phonec2e>y) <br /> City8TAr(<V0(j, I—tg Zip Owner/Operator--if <br /> Check all appropriate services provided: <br /> e Wastewater disposal-compartment sink Electrical hook-ups <br /> olid waste disposal ER/I <br /> preparation a Toilet and handwashin <br /> ot& Cold water for cleaning Is o )ure refrigerated food 0 Potable water g <br /> VStoney dory food/supplies �: Ovemight parking Vehicle wash <br /> I, et / t /.0f,06 , 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 Mall he E immediately. Q 9 <br /> Signature Date/ l la 02-a <br /> 3. To be completed by the ENV HEALTH jurisdiction-o u- t—sid—e of San Joa uin 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 /> a <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 />