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SAN )Q A Q U P N Environmental Health Department <br /> ---COUNTY--- <br /> `- Grecstress groves here. <br /> COMMISSAR' AGREEMENT <br /> Mobile Food Facility t Caterer <br /> Complete sections 1 and 2. if your commissary is locatodo0side of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name 'r'qCLS PA kg ITi~ Lic.Plate# 7 r 8 to y w o <br /> Owner/Operator Name FRRNc(sco .S. EICZ LFav[/IS <br /> Business Mailing Address <br /> Address 333 � 7-m 6T <br /> City.6 C-�(TU' StateC!l Zip 5,206 . Bus. PhCZ6 q 7/S-2616 Alt. Ph. <br /> I, FWCI.SCO T PE&C'z , 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 /> Signature �� h S_ d �l (le e Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name u I o n1" .OTCP( G JrKtA& C&NTcR FA# <br /> Address/ 7/ 7 S. glblg)df 57- Bus. Phone <br /> CityST6CK u0 c6 Zip ?'5266 Owner/Operator Aer -riRx n) <br /> Check all appropriate services provided: <br /> Wastewater disposal 131�3-compartment sink E Electrical hook-ups <br /> r7'Solid waste disposal U'Food preparation toilet and handwashing <br /> EY--Hot&Cold water for cleaning a Store refrigerated food ErPotable water <br /> Il Store dry f000d//ssupplies 13&ernight parking Vehicle wash <br /> SCL 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 II notify the EHD im/�ediately. _ <br /> Signature /L Date o� Z <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in Califomia 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 />