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� S Q orf Q Q Q U I N Environmental Health Department <br />—COUNTY— <br />.cw.r <br />Greotness grows here. <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 Name Lic. Plate# <br />Owner/OperatorNameM li& h, REA- llndell A. RKPWDSa <br />Business Mailing Address 23.Z P46W 091 AE 65Z)&I, <br />City�?AytrZi} State�ZipZ6337 Bus. Pt i -y-93111 Alt. Ph. <br />I c /(.,? -Z— , hereby state that the above information is current, true and correct to <br />the Sest 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 � �� Date <br />12. To be completed by COMMISSARY OWNER/OPERATOR I <br />Commissary <br />Address -1 7,1 7 5, YA 116 JLr 5Z Bus. F <br />City.O ( �4 CA Zip oZ( Owner/Operator. <br />Check all appropriate services provided: <br />Wastewater disposal �3ompartment sink electrical hook-ups <br />Q�-c <br />Solid waste disposal Food preparation ®'toilet and handwashing <br />��/Hot & Cold water for cleaning ore refrigerated food [Potable water <br />I3 Stored food/supplies lies lki M/ <br />ry / pp Overnight pafking Lti7 Vehicle 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 cogditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owneffff hal oti the PHD immediately. <br />Signature Date ` 1161 D 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 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 <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 />L <br />