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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> _ ureotncss grows hers. <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 completed by APPLICANT <br /> Business Name 7 CD.S CO kk,5A Lic. Plate# du 22236 <br /> Owner/Operator Name MR URIC t a (OMA <br /> Business Mailing Address b?r 7 S, PR EST Rl� <br /> City ENCN I�StateAZip UZ,3i Bus. Pr�10 463-71 7 Alt. Ph. <br /> I, in (0 Co CA 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 /> Signaturer(S\n oY l Q.;r Date 1.2, 0 2 0 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name (�Jl�(0'Irll G�9TR( G �I�uG(� �CNT�� FaA# <br /> Address (717 S. ryryuAlt 0AI s� Bus. Phon <br /> CitySTnf <br /> C , Cft Zip 9,6� L 0 Owner/OperatoWv <br /> Check all appropriate services provided: <br /> ER/Wastewater disposal 02(3-compartment sink [2'Electrical hook-ups <br /> —/Solid waste disposal 'Food preparation /Toilet and handwashing <br /> MHot& Cold water for cleaning V store refrigerated food O/F otable water <br /> [3/Store dry food/supplies lam" Overnight parking WVehicle wash <br /> I, ( (k A b 0 , 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 ownersh oti media ly. <br /> Signature Date /o2�sU 2- d <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 <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 />