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REHS Signature_ <br />'1 /4';,N JOAQUIN Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />ComPlefe sections 1 :end 2. If yoW Gomm ssa.ry /a Faceted autslcie of San Joaquin Calmly also complete section 3. <br />LI,To_be completed by APPLICANT <br />ryOZDO LiC. Plate # ilLgLyez_4/5 <br />Owner]Operator Narne217/tiiki Cqra_03 ,Z1f114EZ-• <br />Business Mailing Address ._4:i EAR , AVE <br />city_MO))E5'70 State cA Zip_753 Bus, lih.0?— 7ZZ-5149Att. Ph. <br /> . hereby slate that the above Informatior is current, title and correct to <br />the best of my knowledge ard agree to utlize ny ap.oroved commissary in accordance with Cal-trams/a Health & <br />Safety Code, and Sari Joaquin County Environmental Health Department fEHD) requirements. If the use of the <br />commissary is discontinued, the permit hclder must notify Iho EFID. Fuilu re. lo notify this off ce may result in permit <br />navocatien and penalties. <br />Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name ififArei __1441 met FAP <br />Address 121' .5. Bus_ Phone C2-133g - 3461, <br />City Mocjok) Zip 615551 Owner/Operator GM,/ ea— c?,,-6.4,psi--E <br />Check all appropriate services provided: <br />E'Wastewater disposal <br /> <br />13--;-3-campartment sink <br /> El Electrical hook-ups <br />ErSolid waste disposal <br /> <br />rartood preparation Toilet and handwashing <br />freHot & Cold water for cleaning <br /> <br />O Store refrigerated food <br /> 015otable water <br />Store dry food/supplies <br /> O Overnight parking <br /> Gr/ohicle wash <br />I. Me k Les CArv , nereby state lhat the information I have prov.ded Is current, trie and <br />correct to the best of my knowledge, arid meets the California Health & Safety Code requirements, If the food facility <br />operator falls to comply with the conditions of this agreement, or If this agreement Is modified or cancelled, the <br />commissary owner stra the EHD immediately'. <br /> <br />_Date_f,fr <br />[3. To be completectby the ENV HEALTH prIscliction outside of San Joa_quin Co <br />The commissary Is located in County. The above food facilr,j moats the <br />commissary requirements in California Health & Safety Code. The atiove checkud services arc avaisable at the <br />above commissary. Pica fy EH D if btu status of their operating permit changes. <br />ni a-brach Di., gigizq <br />. 1868 E Hezellon Avenue I Stockton, California 952051 T 209 468-3420i F 2(19 464-13138 I 1111-sjgcri.or g!ohd <br />Business Name <br />Dale