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SAN 10A0UIN Environmental Health Department <br /> COUNTY <br /> Greotness grmvs iwrr <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 /> 1. To be completed by APPLICANT <br /> Business Name I-4,holo, a��rc.r,1 s, LILL Lic.Plate# <br /> Owner/Operator Name S"A AArl <br /> Business Mailing Address S� q�, nqS o <br /> City State CA.Zip y Bus. Ph. ` 'K'-`Isl - ( 14 Alt. Ph. <br /> I, S c t,A 1A-A, ,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. Q <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNEWOPERATOR <br /> Commissary Name lwlaylS " 14�411041 FA# <br /> Address IID N. [I T:>nrcA-p SA. Bus. Phone Ly1- 9ql- Zlo� <br /> City 40 l�01' Zip 5S10-L Owner/Operator <br /> Check all appropriate services provided: <br /> 0 <br /> [3 Wastewater disposal EY33-compartment sink Electrical hook-ups <br /> [!]'Solid waste disposal 18/"FFood preparation [IFfoilet and handwashing <br /> 6 Hot&Cold water for cleaning [Y Store refrigerated food ❑ Potable water <br /> Store dry food/supplies ❑ Overnight parking ❑ Vehicle 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 ow II notify the EHD immediately. I <br /> Signature Date l D l <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br />