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commissary owner hall otl lately. <br />Signature • Date NT7 1' i I 1r5 1 70211 <br />IM <br />SANAAQUIN <br />— COUNTY — <br />Greatness (yaws itcrc. <br />Environmental Health Department <br />RECEIVED <br />COMMISSARY AGREEMENT A" 17 <br /> 2324 <br />Mobile Food Facility • Caterer AVIRONMEN UAL. ALP <br />PERMIT/SLRVICES <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section <br />To be completed by APPLICANT <br />Business Name , Ta_,c <br />Owner/Operator Name YACNk gi2F R-A‘ <br />Business Mailing Address3216 1 NI f PNE <br />City MkNI t CA state a zip 153aosaa. ph.(2001 )(imp '(tj Ph. <br />I, Y Pt PtEL 13M2-FE , ereby 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 acid penalties. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />VNION CATFIZIN frUCg-1 IQ ei OW NI !SS it-i242y Commissary Name <br />Address 17 11 3• 1) N ION Sr Bus. Phone <br />City SIT( Icib N zip 1 520CP Owner/Operator P---DS I g ENE Ti le-PkVo <br />Check all appropriate services provided: " 0\I E-I2-N lei ti-T- ,, <br />)t( <br />Wastewater disposal )0 3-compartment sink Electrical hook-ups <br />i Solid waste disposal Food preparation ilf Toilet and handwashing <br />Hot & Cold water for cleaning Store refrigerated food Potable water <br />Stor dry food/supplies Overnight parking Vehicle wash <br />I, ESI K-Ps 6SA- , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with cond. ons of this agreement, or if this agreement is modified or cancelled, the <br />Ko Is TA COS Lic. Plate # <br />Date 19 ri t.. 02/1 <br />3. To be complet e ENV I LTH jurisdiction outside of San Joaquin Co. <br />The commissary is loca 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 I T 209 468-3420 F 209 464-0138 I www.sjgov.org/ehd <br />fRoSt-Heli-i5