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-� 4 + � � � <br /> SAN. JUAQUIN Environmental Health Department <br /> COUNTY-- <br /> ... L�, nrnrs: r,r,.»•. Err, <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facllityr Caterer <br /> Complete seChons t and 2. it your commissary Is located outsldo of son Joaquin county atso compfole seclron 3. <br /> 1. To be completed by APPLICANT - — - —— <br /> Business N.)mc_ F�akinak Bazar Food Lic. Plate#_-11I B4 482 <br /> Owner/Opermtor Name Mannreet Sir}gtt Sr8 <br /> Business Mailing Address 2151 k1offat Blvd <br /> City LiIntec z., _ ____Mate CA 7ip 95336 Bus. Ph_ 408-998-7019 Alt. <br /> Ph. <br /> I, Mad hereby State that the above information is current,true and correct to the best of my <br /> knawledgo and agree to utilize. my approved commissary in accordance with Califomia Health & Safety Code, <br /> and San Joaquin County Ernuorimental Health Department (EHD) requirements. If the use of the commissary <br /> is disconbrntF_-a, the permit holder mustZth <br /> and penatties. e EHD Failure to notify this office may resatt in permit revocation <br /> 59nWr'Ure oate C,4 <br /> 2. To be completed by, COMMISSARY OWNER/OPERATOR <br /> Commissary Name -' FA# <br /> Address �ZD Bus. Phon _ <br /> City Zip S { Owner/Operator "1~ <br /> Check all appropriate services provided., C <br /> 1� Wastewater disposal St 3-compartment sink 0 Electrical hook-ups <br /> Solid waste disposal 0 Food preparation Q Toilet and handwashing <br /> Hot& Cold water for cleaning ❑ Store refrigerated food Q' Potable water <br /> 0 Store dry food/suppiies 14 Overnight parking Vehicle wash <br /> hereby state that the information l have provided is current, true and <br /> correct to the best of owledge.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 owner shall slotify the EHD immediately, <br /> Signature /j - Date l Zl <br /> 3. To be pleted by the ENV HEALTH1urisdiction outsidt: of San Joaquin Co. <br /> The Commissary is located In County, The above food lacility meets the <br /> commissary requirements In Califomia Health & SafetyCoda. The above chocked services are available at the <br /> above commissary. Please notify EHO If the status of their operating permit changes. <br /> REHS signature Oato <br /> it:68 E. Hazelton Aw-noue I Stockton,Calrlufwa 95205 T 209 46tl-3420 I F 209 464-0138 1 tiH��..sj9ov,orgr'ehd <br />