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1 .jnF.GUIFJ C. <br /> W; SANS OAQUIN Environmental Health Department <br /> —COUNTY— <br /> �;.;_ aa': Grectness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility♦ Caterer 12 <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 p <br /> Business Name. Nwyw n ±a_ rel t� S Lic. Plate#_ (oP 20 S 9 I <br /> Owner/Operator Name "Q1 Y 4u_ tp`s''o�"�(� , <br /> Business Mailing Address 1 e.car.r.�, ttMf <br /> City `ftn p Statef Zip Bus. Ph_ W Obs Alt. Ph. <br /> I, Uruyj )b-e, 4^y4- ,hereby state that the above information is current,true and correct to <br /> the best of m 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 per 't holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p nalties. <br /> SignatureDate 11423 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Ss mm\SSCfv 1 C rZ-�P('(T FA# <br /> Address 07-0 `_=1— Bus. Phon O Z — 33 <br /> City La- l Zip 01SZL10 Owner/Operatorov ( 080RINODW CACO'q <br /> Check all appropriate services provided: <br /> X Wastewater disposal If 3-compartment sink Electrical hook-ups <br /> JISolid waste disposal p ood preparation Toilet and handwashing <br /> 11 Hot & Cold water for cleaning Store refrigerated food `21Potable water <br /> I f Sore dry food/supplies Overnight parking /CL,Vehicle wash <br /> I, Wkmsw aL43= hereby state that the information I have provided is current,true and <br /> correct to the best of inowledge,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 owner shall no the EHD immediately. I <br /> Signature Date__D1 D 2 <br /> 3. To be cftpleted.by the ENV HEALTH jurisdiction outside of San Joa gin 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 /> RENS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />