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SAN JOAGIIIN Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 4 Caterer <br />Complefe secfrons l and 2 If your commissary is located oulsOe of San Joaquin County also compkfe section 3 <br />J. To be completed by APPLICANT <br />Business Name Go > A tT"--A Lic Plate# � MIJ8c31 <br />Owned0peratorName -SA'YE AW_c-GD CA j>lo <br />Business Mailing Address 41 S- rs, \JEfJiuw_,,b6 <br />CityTsIDJUTA"00L0. EState CAZtp RS_ -,"9I Bus. Ph.70q-540-9553 Alt. Ph 40$-Sbc?-$SZ.3 <br />I, _-r&`l kFG, hereby slate 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 Fa4ure to notify this office may result in permit <br />revocation and penalties / <br />Signature �. ,'— — Date S! 1,5_ /Z <br />i 2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName A141 o fJ C ATTR I k,]RVrk FA# <br />Addressf%l7k$. t4atoA( s -r Bus. Phone(�?'0q�-2981-.�-1046 <br />City 5TR i:66 J Cit Ztp9sz o e />-rC Owner/Operator (i(.l% �F--��r f 1 / x a d <br />Check all appropriate services provided <br />E-- Wastewater disposal GY$-compartment sink O'Electncal hook-ups <br />CY�olid waste disposal mood preparation ET�Todet and handwashmg <br />C7 I jet8 Cold water for cleaning C/Store refrigerated food Potable water <br />ET /Store d�ryry ff ood/su plieyst /� @�vermght parking M Vehicle wash <br />I. A /k. ( �te i l f 1 () , 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 fads to comply with the conditions of this agreement or if this agreement is modified or cancelled. the <br />commissary owner al o- th HD immediately <br />Signature Date E / i <br />'. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />Tne 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 952051 T 209 468-3420 1 F 209 46"'! 38 1 www s)gov.org/ehd <br />