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ro S A N J 0 A 0 U I N 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 0 E?_�e_ dbU GS Lic.Plate# DKz 7112- <br /> Owner/Operator Name Ouba t-- I l/b ftm5 ffi 8+ k L$ <br /> Business Mailing Address Y62-7 G{6 Tl W TO I� L, 1`�. <br /> City5T()C-WW State LA Zip 9,520 Bus. Ph. o`t/ 603-i2B2—Alt. Ph. <br /> I, �J eN��i.t. TNsrvtAs /11eRRIS, 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 p9enaltie/$) /) f <br /> Signature it):ca�1C9Q x4t ? / Date_ g!3 1 �2- _2 <br /> 2. To be completed by COMMISSARY OWNERIQPERATOR <br /> CommissaryName 6- I�K(64 TRC{WK CE01M FA# <br /> Address 17(7 S . u01D11LS 5T Bus. Phone uta <br /> CitySTO.W50, d-A zip '.S20(0 Owner/Operator Q4 4W6 00,e5RATr4) <br /> Check all appropriate services provided: A107_rSX ST RNGC D F TR1t1&El2 <br /> Wastewater disposal O 3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> 0 Hot& Cold water for cleaning ❑ Store refrigerated food ePotable water <br /> 0 Store dry fo_od�/sup�pliies 13 Overnight parking E3 Vehicle wash <br /> 1, f�o� t l t A r V , 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 a mediately. <br /> Signature / y�� l Date �J� 1 \ 2- <br /> 3. <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of.San Joaquin 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 />