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SAN =10AQUIN Environmental Health Department <br /> —COUNTY <br /> (, reni r,'cs qrr ss lyre. <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 /> Business Namelt qs /d&= 141 NO/T-4 Lic. Plate# Y T//76 S_7 <br /> Owner/Operator Name GEkrnAP F. LeP£z. MAKTtj <br /> Business Mailing Address 7631 r,0Z56M WAy <br /> City1VhA11Tcy StateC1,zipIS33377 Bus. Phy°a15-W-63(o? Alt. Ph. <br /> I, C JGRMAA1 F. LD Pi5Z 010,1 reby state that the above information is current,true and correctto <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,thet permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe aIties. f �/ �( <br /> Signature � -+� Date ly/? T <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UAIWl 047-AR16 ruck eEP112rA# <br /> Address17174 a-Ah onl ST-. Bus. Phone 0202)-2 S`/ .6 <br /> City�%OG1CT6'l1f CA zip g5ZOg Owner/Operator /?R7- �FbYby <br /> Check all appropriate services provided: <br /> (Wastewater disposal C't 3-compartment sink Lyf E�lectrical hook-ups <br /> Solid waste disposal �W�ood preparation M Toilet and handwashing <br /> I I Hot& Cold water for cleaning f�.tYstore refrigerated food ePotable water <br /> EeStore d/rfo� d/su�p l-iesbq� GYOvernight� parking M"Vehicle wash <br /> I, �/C f F / " I7 Q do , 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 owners no e E imm lately. <br /> Signature c�`%` % 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 />