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SAN JOAQUIN Environmental Health Department <br /> COU <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 /> r _ <br /> Business Name ofer\cLS TQC r3c tttcA _ Lic. Plate#usj? �jrJt{9 <br /> Owner/Operator Name <br /> Business Mailing Address 21'21 tU JC hP lk R <br /> City C= F (' S St`ateCA Zip Ci ' 0 Bus. Ph2o�j_g SSS-30 tS Alt. Ph.Wq-9Il x- 8&0 Z <br /> I, >1�taC�r "Q_0 A02_C , 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 pe aloes. <br /> Signature � Date 10-2-Co-7-02t3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary NameS,4`da�Lor 7�der\Ao'Zc_ • FA# <br /> Address2S aD M,}c hell RC - Bus. Phone 2oc `-538- 30 IS <br /> City CCI LS Zip L P) °4�1Z?Owner/Operator SuuGA0(_ eld 0ZQ- ' <br /> Check all appropriate services provided: <br /> CNastewater disposal I;1 3-compartment sink 13 Electrical hook-ups <br /> 45�solid waste disposal 0 Food preparation EToilet and handwashing <br /> 0 Hot &Cold water for cleaning 13 Store refrigerated food Potable water <br /> [3 Store dry food/supplies 0 Overnight parking 0 Vehicle wash <br /> I, SQ tuako r fiIe ) `0 Z0.-•, 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 cogditions.of-this agreement, or if this agreement is modified or cancelled, the <br /> commissary <br /> owners II c7 otify the EHD immediately. <br /> Signature) c.{yaia_ Date t -ZIo- _L0 Z ` <br /> 3, To be completed by theENVHEALTH.:'udsdiction. outsid0-bf,San Joaquin Co <br /> The commissary is located in S (Q V S , County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checkedservices are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> S? .\ <br /> REHSSignaturn Date 1�-2to ZdZ� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209468-34201 F 209464-0138 vnrnv.sjgov.org!ehd <br />