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SKJOAQUIN Environmental Health Department <br /> " ,'' ' C(D U N T Y-- <br /> Greatness glows 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 com leted b APPLICANT <br /> Business Name �7 [N�j 1 S -T �� Lic. Plate# Z� <br /> Owner/Operator Name?ksuA (k LN PA A—y <br /> Address dress 1� <br /> City Mailin teuZip 1523 Bus. Ph. Alt. PhVq <br /> IY K1 (AA P"- 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 pen ties. <br /> j 1 <br /> Signatur Date <br /> 2. To be com leted b COMMISSARY OWNER/OPERATOR <br /> Commissary Name Vlh WA# <br /> 1 � L <br /> Address J� (/� 0I` Bus. Phone a` <br /> City L Zip Owner/Operator YOS <br /> Check all appropriate services provideed:: C� <br /> 13-S, <br /> astewater disposal C'T3-compartment sink Electrical hook-ups <br /> p--Solid waste disposal [3 Food preparation 011oilet and handwashing <br /> Hot & Cold water for cleaning tore refrigerated food G"rootable water <br /> Gore dry food/supplies Q-6vernight parking G<ehicle wash <br /> I, , 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 con itions of this a reement, or if this agreement is modified or cancelled, the <br /> commissa owne shall nify the E immediately. /] <br /> Signature Date G- <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 />