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)�PpL `G <br /> • x�, S A N.�Ja A QU I N Environmental Health Department <br /> COUNTY— <br /> e9 �. ureoiness grows here. <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 OLD:s L,.n cme,i 9e, Lic. Plate# 7_44 6 x mom_ <br /> Owner/Operator Name k cnan to C /v1, lqi�L L lA LC 47 <br /> Business Mailing Address 7_ �( '� At*4 r2 rpt � <br /> City r,r jg�t States�Zip_L Bus. Ph.(j�,c,>y�_,, iS Alt. Ph.6 nq 7L t i <br /> I, 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 ,nftr„�,1;dlr_, guy)14914 AaDate <br /> 2. To be completed byCOMMISSARY OWNER/OPERATOR <br /> Commissary N//a��me -71 <br /> CI.� ! Knyt'y� a.., -� ii�r ' Tr `rW FA# <br /> Nj <br /> Address a 7 q(,-) . A %,r VV)r Bus. Phone f- 9 - 22- ) — 9 <br /> City C_24-C)C'k(--u n°) Zip Owner/ peratf>- <br /> Check all appropriate services provided: <br /> p/(Nastewater disposal 0.5-'compartment sink Electrical hook-ups <br /> CT/Solid waste disposal 13 Food preparation Cr"Toilet and handwashing <br /> �04Ho & Cold water for cleaning --//Store refrigerated food ["Potable water <br /> Store dry food/supplies 12/overnight parking UYVehicle wash <br /> I, IC�e,,�5 c'y hereby state that the information I have provided is current,true and <br /> correct to the est 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 owner shall notify the EHD immediately. I <br /> Signature Date lo <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 & 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.org/ehd <br />