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row"'"�•. <br /> r ; , SKJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness 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 13 b-eqS '060clGis Lic.Plate#_'i /CZ 71/ 2- <br /> Owner/Operator Name WEAD6LL 7i1I'1115 fl?&kkL5 <br /> Business Mailing Address 2 G{6 T)6�TOO11 L �. <br /> CityST®CVJV( State LA Zip 152a Bus. Ph. °q/ ( 03-6252-Alt. Ph. <br /> I, LJ�N1�E►.l_ TW®tv>, McRRL5,hereby state that the above information is current,true and correctto <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 ,rtieg. _ ` ' <br /> 2 ;k- 'V' <br /> Signature�,� ca� IX)�(C/ � / Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName Uthb(; 0- KINICi TMCK CEO-VEk FA# <br /> Address l-](7 S , (,1t,1ic>Sil 5T Bus. Phone aoqmeq/$-Sy/4 <br /> Citys-roal 1JI CA Zip CIS206 Owner/Operator e0 WDP,fRA-r4K <br /> Check all appropriate services provided: Ali %rbX ST rQRGC DF )qtl1G-E2 <br /> Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ()Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food Potable water <br /> ❑ Stored y food/supplies ❑ Overnight parking 13 Vehicle wash <br /> AK I 1 <br /> I, f 1\4ft d , 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 ow shall��--oti--f��y� a EHD' mediately. Q <br /> Signature 2= Date //13 �- <br /> 3. To be com ,Ipted by the ENV HEALTH jurisdic Ms'.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.sigov.org/ehd <br />