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SAN JOAQUIN <br />Environmental Health Department <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 />11. To be completed by APPLICANT I <br />I 6(U GRo%cP s t c <br />Business Name�K D� {� SCE /li b al b3 C s 5 ri)e Lic. Plate # &994 5 <br />Owner/Operator NameoERil g rE Pui4 431-CITW 040'o'4P L,l—S- <br />Business Mailing Address 175 PRAI RE LAiI <br />city_S'_bLk-TD6 State I�1 Zip_2LZ&Q Bus. Ph. -30/04"Alt. <br />I , 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 & N (d t j C ►4fMM(I -CRuCk CEn1 tiff- fz FA# <br />Address 717 S Ukfoti) ST Bus. Phone �t <br />citySTcpa- V C6 Zip252bt7 Owner/Operator BUAIA ErfC !'u/" <br />Check all appropriate services provided: <br />G(�Wastewater disposal 0 3 -compartment sink 1.0 Electrical hook-ups <br />h_2 Solid waste disposal C? Food preparation 0 Toilet and handwashing <br />D. Hot & Cold water for cleaning D Store refrigerated food '!KPotable water <br />Store dry food/ u pplies 0 Overnight parking D Vehicle wash <br />I, /�®® f/CC 11 I /�� 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 own shall noti� the E D immediately. <br />_ginnnhira Z' s I _� Date / 013 ( 12 62, 2 <br />3. To be completed 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 <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 />