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SAN JOAQUIN Environmental Health Department <br />UNTY— <br />g1o.5 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 SeCrtf SCuu_Q TACOS "d 7-01AS Lemic. Plate # <br />Owner/Operator NamesRfL-Thio ©r+i-,L <br />Business Mailing Address 901 g CA.V"Sig (2+ <br />City S-H&Lfm State C4Zip 9S2D I Bus. Ph.,Zbl (/23 S,fgriAlt. Ph. <br />I, S fX�%1D �V ♦'1 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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address q12 W <br />FM <br />\10WMiFe <br />Phone <br />Zip als,>n Owner/Operator 1 i.. <br />FA# 0002_ V <br />2o4)- y -C(a W -:� <br />Check all appropriate services provided: <br />Wastewater disposal 3 -compartment sink ❑ Electrical hook-ups <br />0 Solid waste disposal Food preparation ZllToilet and handwashing <br />Hot & Cold water for cleaning tore refrigerated food ❑ Potable water <br />❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br />I, LGmva (9R r6a , 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 fail5.to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />EHD immediately. �I2) 2Z <br />1 3. To be-eembleted by the ENV HEALTH iurisdiction o`Mffe'bf San Joaai51111111111111111111111 <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 Sig <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 />