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SQ N >�Q QQ N Environmental Health Department <br /> —COUNTY— <br /> Greotness 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. Tobe completed by..ARPLICANT :}'., _______ <br /> Business Name.-_M04hOW Zv KA_ Lic. Plate#_qLjCR-2, 5-0- _ <br /> Owner/Operator Name_!SNA_ r/-/ T4 <br /> Business Mailing AddressAe_V 7 L09 J- ID—0 <br /> CitySA/jkQ�/ Stateo ZipBus. Ph.9ff,-90-1077Alt. Ph. 92S-��Ll <br /> I, IS NA MF Hn 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 O _ <br /> 2:To be completed*b ' COMMISSARY OWNER/OPERATOR <br /> Commissary Name 1 O / FA# k <br /> Bus. Phone <br /> Address //�� `.Cp??ri! r1! y� __ —�� <br /> Ci 44 Zip C/ Owner/operators/45 <br /> Check all appropriate services provided: <br /> Wastewater disposal 4 3-compartment sink Electrical hook-ups <br /> G-Solid waste disposal Jk Food preparation 09joilet and handwashing <br /> P Hot& Cold water for cleaning a Store refrigerated food Potable water <br /> 3OLStore dry food/supplies tjWovernight parking ASQehicle wash <br /> hereby state that the information I have provided is current,true and <br /> ane <br /> the California Health&Safety Code requirements. If the food facility <br /> correct to the best of my knowledge,and <br /> operator fails to comply withthe condi ns of this agreement, or if this agreement is modified or cancelled, the <br /> commissary offer shall Wtify the D'immediately. <br /> Signature Dater <br /> (.5:-To be pletedl y the ENV HEALTtH16hsdiction outside of San Jou n Co. <br /> The commissary is located in COv �� b`R 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 /> ` AESFS � � 23 <br /> E�EHS Signature_ ,�„^� EM No Date_� _ <br /> 1868 E. Hazelton Avenue I Stockton,Calif95205 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> OVHM . MOHSEN (DiHEALTiA ,0QG <br />