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f <br /> A .J DAN I Environmental Health Department <br /> .._� C O u N a <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 7 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> . Ta be com leted - b APPLICANT 11 <br /> Business blamer ad- "d ) ZIOV/ riA Lic. Plate # . <br /> k <br /> Owner/Operator Name LI r -` <br /> Business ailing Address /eje' f', IL/4 L6=1 I <br /> State&-1 zip ' s pus. Ph ,2i y w cv2 71 - 3c) E3-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 holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a d penallties. <br /> Signature Il\� 6 � Date J _ � <br /> k2. To. b6 completed b COMMISSARY O11 W RIOPERATOR <br /> CommissaryName /Gi �c � FA# <br /> Address4�9N 9 e l� , / Bus. Phone <br /> City' sy7 Zip 9 c9US caner/Operator <br /> Check all appropriate services provided : <br /> Xj Wastewater disposal Irl 3-compartment sink Electrical hookups <br /> 22 Solid waste disposal Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Store refri%prated food Potable water <br /> Z S dryfoodfsuppliesem Overnight parking Vehicle wash <br /> i , �N✓t/i TZ5 Ow <br /> /�>de , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and " is the California Health & Safety Code requirements. If the food facility = <br /> operator fails5wnFrshall <br /> mply with the con ons of this agreement, or if this agreement is modified or cancelled, the <br /> commissa notify thb - immediately. <br /> Signature s—� � . . Date / ` G – o? � /✓ <br /> 3, Tobe corn` leti d by the ENV HEALTH ' unsdiction outside &. San Joa uin Go. <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 /> RENS Signature Date <br /> 1868 E. Hazelton Avenue 1 Stockton, Catifarnia 95205 1 T 209 46&3420 1 F 209 464-01 36 1 wwwr.sjgov.orgfe9 id <br />