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jANJQAQU ( N Environmental Health Department <br /> -C SUN <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility m 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 [H (,Q'�5 TAQuC-1/1 Lic. Plate# 71141543 <br /> Owner/Operator Name M Rf A DC LMuK10 MttRTin��z- MARTn/c�z <br /> Business Mailing Address -I � q c. AL�nj&1 h sr. Wloy <br /> CitymaNx«} State C4 Zip"4 Bus. Ph.@0315- 133 0 Alt. Ph. <br /> I, lU A6?I R h, M R �T lU hereby state that the above information is current,true and correct to <br /> the best of my knowledgeand 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 ?(1712-1 <br /> 2. To be completed by.COMMISSARY OWNER/OPERATOR <br /> Commissary Name iNPOy Cl"?r6- ffila ,t',,t eEW-�!t FA# <br /> Address .1 t l -7"55 PN(()1\) 5T. Bus. Phonne(2-r-1) Z �F-5��lC <br /> City J`r CKTftjI C/� Zip . b Owner/Operator M-7—L 12fip � <br /> Check all appropriate services provided: <br /> .Wastewater disposal E7`3-compartment sink V'Electrical hook-ups <br /> Solid waste disposal 3 Food preparation Toilet and handwashing <br /> dHot& Cold water for cleaning i" Store refrigerated food _Potable water <br /> �s�tore dry food/suppliesQ Overnight parking ii1 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 conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owners <br /> IIoti D immediately. <br /> Signature Date <br /> 3. To.be cbmpleted .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 wv✓Jv.sjgov.org/ehd <br />