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SAN JOAQUIN Environmental Health Department <br /> Lug. <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 Cu.%�5 TH Q u-c Q i Lic. Plate# 7114 154 3 <br /> Owner/Operator Name MllKfA bci-R&,s f to MI�KTIA1Ez MARTI��Z- <br /> Business Mailing Address -I � q it-, f�y� 1�A sT. ii loy <br /> CitymOIy CA State C4 Zip 53J Bus. Ph.0 )$1,5-B 0? Alt. Ph. <br /> I, 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 Date �1 ' 7( L� <br /> e2- <br /> 12. <br /> 72. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name tf(t&)A) C#r6fif)V6 f'l'ack CoFyd Ott FA# <br /> Address -i 7 5. �4Y�{¢) jj S� Bus. PhoCnle(P— 1) <br /> city,57©ciCTA;, C4 Zip .?b6 Owner/Operator <br /> Check all appropriate services provided/: <br /> ^Wastewater disposal �r 3-compartment sink :Electrical hook-ups <br /> Ir(Solid waste disposal '7'l/Food preparation �? Toilet and handwashing <br /> ; Hot&Cold water for cleaning Y Store refrigerated food Potable water <br /> tore dry Tfood/su food/supplies y� �Overright parking Vehicle wash <br /> 1, �s�/ 7/li /�[�6 6 , 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 II ti D immediately. // / <br /> Signature G11 t/'� Date �I/ �. z� <br /> I 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 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 />