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S A N .d O A Q U I N Environmental Health Department <br /> COUNTY <br /> �y 11 <br /> grows <br /> COMMISSARY AGREEMENT <br /> ` Mobile Food Facility * Caterer <br /> F" <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 APPLICANT <br /> Business Name Taw San- F, Lic. Plate# 5131M <br /> Owner/Operator Name Glra BWCU <br /> Business Mailing Address 114 MAGI ie AVe <br /> City S V&h rk State CA Zip q 5ZOq Bus. Ph. Alt. Ph.(101) <br /> I,- u ra RUYU 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. 11 <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name T U -rm 7 4'—__ FA#ra4) <br /> Address c� K-0 Aj )w ANd to pW Bus. Phone(2bj1\ Y(pS—` 2-`FS— <br /> City Q`T��C'1 f�f—� Zip ���o S Owner/Operator ��j i_6 CAe c�1 <br /> Check all appropriate services provided: <br /> ❑ Wastewater disposal 0 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food 0 Potable water <br /> ❑ Store dry food/supplies -. Overnight parking ❑ Vehicle wash <br /> 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 ow e shall notify the EHD immediately. <br /> Signature <br /> Date 12 2 <br /> 3. To be c leted b the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The co sary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checkd services are available at the <br /> ry q permit changes. <br /> above commissary. Please notify EHD if the status of their operating <br /> Date <br /> �• REHS Signature <br /> ia 95205 <br /> T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> 1868 E. Hazelton Avenue I Stockton, Californ <br />