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L , burp <br /> SA-6JOAQUIN Environmental Health Department <br /> L� 4. COUNTY <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Complete sections land 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 He L L C i 6V5e DkjTW.VrJ Lic. Plate# 7 t4(a23 6 j <br /> Owner/Operator Name MWA al ES <br /> Business Mailing Address_ I3 (1 GiAAlAifj LILT <br /> CityIw/�/VZ" State t4 Zip 7,,5-334 Bus. Ph. Alt. Ph. <br /> I, , 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. fl <br /> Signature Date <br /> 2. To be com feted '1 COMMISSARY OWNER/OPERATOR <br /> Commissary Name 0100 U :k1PJ6 JA__L/a CeMoq FA-4 <br /> Address_1 -11 -76. � I CA3 67 Bus. Phone C' t <br /> �J_r, <br /> �q�"Syr 6 <br /> City STOcM$, _ fi Zip 95,7,D lo /t Owner/Operator Rr [ ` R 1?49 <br /> Check all appropriate services provided: <br /> Wastewater disposal 1531"3-compartment sink electrical hook-ups <br /> er"Solid waste disposal ErTood preparation ErToilet and handwashing <br /> of & Cold water for cleaning /Store refrigerated food �Q�Potable water <br /> Store dry foodls pplies [� Overnight parking M Vehicle wash <br /> I, Rg 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 sh ~he E immediat ly. l' <br /> Signature Date /�`'`U ? r <br /> -T-r6-6e com leted'b 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 END 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 />