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• PSA,%JOAQUIN Environmental Health Department <br /> " 1 —COUNTY— <br /> \1. : Grddrtness 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 w_ o Lic.Plate# 'AAA S q S�- <br /> Owner/Operator Name <br /> Business Mailing Address I `-16 Cl a <br /> City fief l o c �State 6-Zip ` S 3 v Bus. Ph. Alt. Ph. <br /> I, o�' � hereby state that the above information is current,true and correct to <br /> the best o my knowle a 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 /> Signature ov^I L- a ��y vt 'L Date <br /> 2 To be completed by COMMISSARY OWNER/OPERATOR Siani <br /> Commissary Name 40 romiSoriA Axes-!Q FA# , <br /> 61 <br /> Address f'o�f'( 3f P-�" Bus. Phone 0209 ja <br /> City_,gg Zip 45351 Owner/Operator S my <br /> Check all appropriate services provided: JENNIFER HEREDIA-HERNANDEZ <br /> Environmental Health Specialisf , <br /> Wastewater disposal ® 3-compartment sink ,® Electrical ENVIRONMENTAL RESOURCES <br /> ® Solid waste disposal 99 Food preparation M Toilet anc Environmental <br /> Health <br /> Division <br /> 3800 cornucopia <br /> fig Hot& Cold water for cleaning ® Store refrigerated food ® Potable% Modesto, CA 95358-9494 <br /> Direct:(209)525-6791 <br /> ,13 Store dry food/supplies ® Overnight parking ® Vehicle w Main:(209)52-9-6700 <br /> Aark <br /> Cell:(209)278-5369 <br /> Lv i5-1^ _, hereby state that the information I have provided Fax:(209)525-6774 <br /> correct to the best of my knowledge,and meets the California Health &Safety Code requirement, Email:ihemandezCaenvres orq <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modifies ,�,wwsta=ountvcor, <br /> commissary owner shall notify the EHD immediately. <br /> � Date 2 2 <br /> Signature /J�`�-`a <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located inCounty. 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 SignatureDate <br /> 1868 E. Hazelton A nue Stockton, California4�rlT209 468-3420 i F 209 464-0138 1 www.sigov.org/ehd <br />