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• •r-� O 02�52� <br /> Q � 5 � bSSCA <br /> SANJOAQUIN Environmental Health Department <br /> --COUNTY--- x- 11 , UMC <br /> Gre,-tn.�ss o�c1�5 hFr.. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility# Caterer <br /> Complete sections i 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 /- UPEG s I's Z- 8r�h V0 Lic. Plate#3X29791 <br /> Owner/Operator Name 7 F-56PJ(A C•y):S (D U j <br /> Business Mailing Address ZG6 3 lk/1111 AVC <br /> CityS7bCkTDA( State efA Zip9 .5o2Dl Bus. Ph.C209),5-/$-?P5`1r Alt. Ph. <br /> I, i 656 0 A Ot,5T(L CO ,hereby state that the above information is current,true and correct to <br /> the best of my knowledge anFagree o utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San oaquiEnvironmental Health Department (EHD) requirements. If the use of the <br /> commissary is discon ' uedthholder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe a es. <br /> Signature Date <br /> 2. To e m tete by CO 19SARY OWNER/OPERATOR <br /> Commisa Name 2FR G 6(ek CEnJT15R FA# <br /> Addres ( 5 . D S T Bus. Pho4(2 i) ,7 !a <br /> 9-5 q1C <br /> City- 7-WT94 , 64 Zip 0L Owner/Operator OT- 0 <br /> Check all appropriate services provided::- <br /> Wastewater disposal 33 compartment sink �/Electrical hook-ups <br /> [Solid waste disposal C-Food preparation 12(Toilet and handwashing <br /> ED/Hot& Cold water for cleaning More refrigerated food 0'/Potable water <br /> G Store[}dryyffood>��p/plliie/st ('Overnight parking UVehicle wash <br /> 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 ownerrpl alll nng�ifyh.ytth/ EHH immediately. <br /> Signature 9/7 n I _.0 Date <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.sigov.org/ehd <br /> V <br />