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"'- SAN:d O AQ U I N Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1.1;'To'be completed by.,APPLICANT.,.'' <br /> Business Name.Molhe s 20 K Lic. Plate# .��_ <br /> Owner/Operator Name_X 14 8 M <br /> Business Mailing Address LIQO `0 4 wa 4fi r /09 )jo m o y <br /> City _i�j 9Stateo Zip. Bus. Ph.9a, -/d97 Alt. Ph. 172S.1,0-16q <br /> I, IS PAhereby 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 END. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date O1L2�?b 9 <br /> 1"27;To be.completed'!'Y'COMMISSARY�OWNER%OPERATOR <br /> Commissary Name ( ' ( D FA# ���14 <br /> Address //(? ��Y7rf i`:9l Bus. Phone_ <br /> City �/-'I* Zip� 52 Owner/Operator C <br /> Check all appropriate services provided: ✓�" <br /> Wastewater disposal A9,3-compartment sink CElectrical hook-ups <br /> G-Solid waste disposal A Food preparation 09joilet and handwashing <br /> �1c . Hot& Cold water for cleaning Ca Store refrigerated food cEX_Potable water <br /> QLStore dry food/supplies �P-Ovemight parking 'fVehicle wash <br /> I , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledgetan�'ets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the cs of this agreement, or if this agreement is modified or cancelled, the <br /> commissary oTv r shall tify the D'immediately. <br /> Signature �/ , __—_-.---Date ,h/, QL <br /> $ To-be c �leted` tfi®ENV:HEAL'TH°'urisdictl "i outside of San'Joa ui.n`°Co ' <br /> The commissary is located in _ CUYvA VCf 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 <br /> statusof their operating permit changes. <br /> E2EHS Signature1 I ,OBSOnate_ ��2 3 <br /> 1868 E. Hazelton Avenue I Stockton,Califr95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> `< AVH- M - MOHSEN6i.. -� a G <br /> ��L T IA .02 <br />