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P � Su �o9 � � <br /> SAN ,JOAQUIN Environmental Health Department <br /> --COUNTY- <br /> - <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. Tobe completed by APPLICANT <br /> Business Name 126jCPQiCj"f©l�dS Lic. Plate# 'i til �S to t ICJ <br /> Owner/Operator Name — <br /> Business Mailing Address 6M Sj CI 1 i"an k 1nl kid <br /> Citv,4 crcAnVX)I(f StateLA_Zip Bus. Ph.61I�2Q2- :Jl5q Alt. PhAQ-1QU-S(e 2- <br /> I, V i r i diann Nano jP.S hereby state that the above information is current,true and correct to <br /> the best of my knowledg6 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 an) penalties. <br /> Signature j ridj04 - G Date O9_ / 1 /2 1 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR. <br /> Commissary Name IC(` h0 pa I P-1-6% FA#_00 I(D-4Q <br /> AadressP;4ol PrranKl in r`Wick Bus. Phone cl10-m2 - 'i i501 <br /> City<r2C ^3MP'r '[n Zip6lS4i?-Zi Owner/Operator j i r i i C nck Nnpo i eS <br /> Check all appropriate services provided: <br /> Wastewater disposal Er3-compartment sink ;Electrical hook-ups <br /> jd Solid waste disposal Food preparation &Toilet and handwashing <br /> 2f Hot& Cold water for cleaning Ur//Store refrigerated food id Potable water <br /> (Store dry food/supplies 9 Overnight parking Cl Vehicle wash <br /> I, Vir i d►ana NapaleS , 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 thec ditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o er shall noti t HD immediateI <br /> Signature ✓^7` ran n g Date Osf Y 7191 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in _k2ay_r6ii4m, County. The above food facility meets the <br /> commissary requirements in California Healfh & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD <br /> EHD if the stat of their operating permit changes. <br /> REHS Signature �/ I Date U Z <br /> f Of <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd c <br /> J <br />