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SAN MAUR, Environment;:i. Health Department <br />—COUNTY <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 />To be completed by APPLICANT <br />Business Name OfIVC.: BC SONS Filmbus HT <br />Owner/Operator Name b fIJt D ALLEN <br />Lic. Plate # <br /> <br />Business Mailing Address I z.0 pEttitie,84(<6,? /„J #/ 85 <br />City VA filtriee 17 State Cft Zip 953:i6 Bus. Ph.k04) C87 -90? Alt. Ph. --------- <br />, 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 • ierija: notify the EHD. Failure to notify this office may result in permit <br />/111411W <br />revocatio • • • alties. 4 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name UMiOA) ctiTEW/MG -/Tetkc cErJTEg FA# <br />Address 7 1 7 s . AJ//'J S7 Bus. Phone aw9),293-.5-wz <br />City 67O CiCres tO, 611 Zip ?,_ce.2 O e. Owner/Operator <br />Check all appropriate services provided: <br />Gy Wastewater disposal P13-compartment sink <br />E( Solid waste disposal ElFood preparation <br />r"Hot & Cold water for cleaning C2/Store refrigerated food <br />ri Store dry food/supplies .,2."Overnight parking <br />I, /her 74/9p6 <br />commissary owne hall ify th EHD im ediately. <br />Date /2 5 4 <br /> <br />Signature <br /> <br />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 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />p A u(0 fiLLEAJ <br />Signatu Date (312 GS 2. <br />ther 14.406 <br />El Electrical hook-ups <br />0/Toilet and handwashing <br />Potable water <br />'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