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, t <br /> SAN JOAQUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3 <br /> TRAW <br /> yI/ <br /> Yf tkr <br /> Business Name CQ, `\ bcr�-C'\'rN s L 3CWS Lic. Plate# <br /> Owner/Operator Name C�r 1yS C arc SDS i <br /> Business Mailing Address_ 21 �C� VJho�� C+ <br /> City k--QN-- � v U State_�&Zip CAS530 Bus. Ph. 51O-qOq -3-1ti7Alt Ph. <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 /> Signature Date — <br /> 2. To be completed;by C0WfSOARYAtl <br /> Commissary Name StrUtge t WM-Dj)1Wdfn Wltu FA# NSA <br /> Address IUQOO 6oldtnvallfu PKwu Bus. Phone <br /> �20�)23�' gSZI <br /> City �ftlt prop Zip 15330 Owner/Operator <br /> Check all appropriate services provided: <br /> ❑ Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> Q Hot & Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies Ei Overnight parking ❑ Vehicle wash <br /> I. Rarah Leber -,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 owner shall notify the EHD immediately. <br /> ( <br /> Signature wo A Date 111 2.0�4 <br /> ( 3 To ba co >pld' lV�/ HEiA�T � faar� e ofJS ,�oquu <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 />