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SAN Environmental Health Department <br /> _i N TY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Compfefe sev,ons 7 ar?d 2, tf your cor mT7is&ry is iocaled ol'&ide of Son.1{)a&qu1 '7 County atsc. con7ofete. se-c6on J- <br /> ' ^_T^,r!eted by APPLICA14T <br /> Business Narnc tic.Plate#_q G 7 <br /> 2 7 <br /> Ownprioperator Narne <br /> Business Mailing Address. � 4� ?r: <br /> City r�Yl'4'l' tat ,'� Zi�pp_1 �$us. � ,_ �=� ) i Alt Ph. <br /> I, <br /> �f� � ','_. �_.{�4, , hereby state that the above information i4 current,true and romeGt to <br /> the best of m} x.nc,r.lcc ar+ ag,ree to utilize my apprrnrrad commissary in accordance with California Heatth 8� <br /> Safety Code, and Son Joaquin County Environmental Health Departrnent (EHD) requirements. If the use of the <br /> -:*rnmiss.ary iz, di&confintjed, the permit holder must rrotify the EHD_ Failure to notify this office may mull in permit <br /> Sig n3tUrt< -- <br /> 2. To be corn feted by COMMISSARY UVVv cLrj,,r-r--rV, i �,jr-, � <br /> Commissary NameAf, C_,4 1414_6 RtieK (�&O EK FA# <br /> Address / 7/ 7 ,5 . 000A) 57- Bus. Phone 0 <br /> City=—f 'C Q ZiP G_ _ C3wrncrl0pera1or J lfifiD6 <br /> Check all appropriate services provided: <br /> 1f`lfastewater disposal 1313-compartmcrt sink 0"Elecbical hook-ups <br /> LB�Solid waste disposal TF toot preparation 121, oilet and handwashing <br /> M'Hot & Cold water for cleaning 12'Stare refric <br /> ,jerated food C ' Pcxtabic water <br /> 21'Store airy foodisrt ie's U'Ovemight parking Vehicle wash <br /> I, j l f— . 'hereby state that the information I have provided is curren3 true and <br /> correct to the test of my knowledge, and rriects the California Health &Safety CWi requirements.ments. tf the fraud facility <br /> operator faits to comply wim the conditions of this agreement, or if this afire en-pint is modified or cancelled, the <br /> commissary owner sh l notify tiv EHD mmodlately_ <br /> Si nature L7atu <br /> 3_ To be completed by the ENV HEALTH jurisdiction uui siut; ut odi r ,}ueuir r amu= <br /> The ccmmiss3ry is located in C'atinty. The ahove food facility meets :he <br /> commissary requirempnis in California Health & Safety Cade_ The abave c:heckri services are available at the <br /> above commissary. Please notify EHD if the status of their operating pe-mit changes. <br /> REHS Siam;=ture Datta <br /> 1868 E_ HazcItw Avenue l Stockton, Ca3lfornia 952051 T 20941 8r 3%4201 F 20!946,4-0138 j www-stgov.org1ehd <br />