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SANJOAQUIN <br />Environmental Health Departmenl <br />COUNTY <br />h ; <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 />To be completedi*APPLIC <br />Lic. Plate # j/j(-2 5/8 Business Name 130 / H R )9- <br />Owner/Operator Name &7,</R ...0 /2)6;)--/ <br />Business Mailing Address 1 9 6.2 (4‘ 14/e, <br />City MAIA/12..4,e* StateCfo. Zip 9,.S-3;17 Bus. Ph.,..-294/5`7662-Alt. Ph. -49— <br />I, /1,4776 S);4 4/6-_Da , 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 / 4 11 <br />To To be compl A M SSARWOWN RIOPERATOR <br />Commissary Name <br />Address I (p 20J HA, s "NJ :Rd _ Bus. Phone ,20c1 - 7J7- ille % <br />City144411,,,,e Zip sris ;ID Owner/Operator 51"--e.V..e_. RAW) %.. <br />Check all appropriate services provided: <br />a( Wastewater disposal 0 3-compartment sink 1/Electrical hook-ups <br />ri Solid waste disposal 13 Food preparation FiToilet and handwashing <br />0 Hot & Cold water for cleaning 0 Store refrigerated food VPotable water <br />IOvernight parking aKehicle 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 owns hall no dA) e EHD immediately. <br />Signature Ag _ _ ... Date Y25 illr' <br />1 <br /> <br />Date <br /> <br />rvoci f/ 7fFA# 00 ,27193 <br />0 Store dry food/supplies <br />1, St4a,„1/siZr4160,5C,_ <br />3. To b completecthwthd;ENVIHE.ALTHjthisdietiorVo.utside,:ofSan;Joacirpin Co. <br />The commissary 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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />.11/1 ) ddc-e-