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Environmental Health Department <br /> "" .---COU N TY— <br /> COMMISSARY <br /> YCOMMISSARY AGREEMENT <br /> Mobile Food Facility♦ Caterer <br /> Complete sections l and 2. !f your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed <br /> b . APPLICANT <br /> Business Name rT I �' �4 L4 e-lz 1 tt Lic.Plate# 7/ISi&5_6 3 <br /> Owner/Operator Name SINS__ gfi/( i3RL <br /> Business Mailing Address 416ZI e© 5,T4- AZ lj1/E. <br /> City-2L CK7Dg State zip y'Sa a Bus. ria 9 63 ,•��� Alt. Ph. <br /> -51A G O_ _CJ a K) m— ,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—(U&Vjl'�-, --- Date <br /> 2. To be com leted by COMMISSARY OWNEWOPERATOR <br /> Commissary Name Vj lolL/ FA# <br /> Address! 71 7--J, alejdkl 5T. „ _._ Bus. Phone( u`) <br /> City `J 6cK7QAf G Zip ,g�v L_ OwnerlOperator &LI t &,I) <br /> Check all appropriate services provided. _�..,, <br /> [//Wastewater disposal ES/3-compartment sink �'EElectrical hook-ups <br /> 3/Hot <br /> waste disposal �Fbod preparation ��Potable <br /> filet and handwashing <br /> L�' Hot&Cold water for cleaning Store refrigerated toad water <br /> Storedry foodisupplies D'Overnight parking E(Vehicle wash <br /> 1, 6 J.ed �6(?fid 0 , 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 /> commissaryown shall tify th EHD immediately. <br /> Signature^ _,..,.....__,. Date <br /> 3. To be corn feted Py the ENV HEALTH jurisdiction outside of San Joa <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 vrww.sjgov.org/ehd <br />