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SAN J OAQ U I N, Environmental Health Department <br /> COUNTY <br /> {, Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 Taw Sa ns+ R. Lic. Plate# 5131 M Z <br /> Owner/Operator Name Gira Blanco <br /> Business Mailing Address 110 wile Apt <br /> City AAXto Y}, State CA Zip Bus. Ph. �10�) qU I Alt. Ph.�101) (0171-110 <br /> I, (,I ra Blanco , 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 A'151 . <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName Mb U M�' ( � / FA#r�'a� C <br /> Address y1 I� ���W A"I 1���'L Bus. PhoneL2 LA, qc,6—?2�S <br /> City Q-TZ)C'k—%0" Zip Ot(�-2-0 S Owner/Operator djj) Ti`s C t4 �I <br /> Check all appropriate services provided: <br /> E3 Wastewater disposal 0 3-compartment sink [3 Electrical hook-ups <br /> Q Solid waste disposal Cl Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning [3 Store refrigerated food [3 Potable water <br /> Store dry food/supplies Overnight parking 0 Vehicle wash <br /> I, , 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 owe shall notify the EHD immediately. <br /> Signature Date 2 2 <br /> 3. T be leted by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The co i sary 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 />