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S A N J O A Q U 1 N Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Complete sections P and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> l- To be completed by APPLICANT _ <br /> Business Name Shakat I;x uC _---�----���� Lic.Plate# -- <br /> Owner/Operator Name &A tSDq <br /> Business Mailing Address Sqb � �4$q 3 <br /> City �t 1't1 Aka_State C" Zip °I4Id4 Bus. Ph, IM-32g-y04V Aft. Ph. <br /> I, -Dliq rn s WISDLL 1 hereby state that the above information is current,true and correct to <br /> the best of my knowledge and gree 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 p <br /> Signature Date ail 22)2q <br /> 2. To be completed by COMMISSARY OW(NEWPERATOR <br /> Commissary Name /J 2-5/� Cs Fd7to CLI '' r�e� FA#Address Z-f b Ole Y � '1r 1'� �'�f.Bus. Phone 2-C2-60- '? 1 G 2 <br /> City -1 /' rn1 Zip s rr Owner/Operator Ch 9llr`'f PS' <br /> Check all appropriate services provided: <br /> wastewater disposal C7 3- partment sink �ctrical hook-ups <br /> Solid waste disposal Q Food preparation Q'Ztlable <br /> and handwashing <br /> 1U'No A Cold water for cleaning la-lStore refrigerated food m- water <br /> tore dry food/supplies UKO&-ernight parking Vehicle wash <br /> I, t�h /6 f PC 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 con Lions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary own shall IWtify t HO immedial <br /> 5!gnature_Z_..__, <br /> Date <br /> �3 To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in _ -.-... County. The above food facility meets the <br /> commissary requirements in California Health & Safely Code. the above chucked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1668 E Harellon Avenue I Stockton California 952051 T 209 468-3420 1 F 209 464-0138 1 www.slgov.orgiehd <br />