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SAN JOAQUIN Environmental Health Department <br />C, 0 U N T Y----. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility # Caterer <br />Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />o be completed by APPLICANT <br />_MS AM3 6D5 4S -13 - <br />Business Name US Lic. Plate # <br />Owner/OperatorName— K I D A IA - <br />Business Mailing Address ID Wjt�j �:F LL_ <br />CitklV' State rA Zip Bus. Ph.1 �L6 157— 0 <br />�b JAIt. Ph. <br />�A A hereby state that the above information is current, true and correct to <br />the best of my knowled8e, aagree 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- Date <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Namec&l-fqf'p� I A <br />7�n 2 - <br />Add ress C) CA Bus. Phone <br />City c', —ZIP Owner/Operatori <br />Check all appropriate services provided: <br />Cr-�Yastewater disposal EZ 3 -compartment sink U/61ectrical hook-ups <br />�J9 Ud waste disposal 8"F od preparation 0"Kilet and handwashing <br />a I <br />(3 Hot & Cold water for cleaning refrigerated food Po le water <br />0' <br />Overnight parking Vehicle I St e d fTID(od/sup re �/=cle wash <br />Ws Overn <br />V)lunvAz _—, hereby state that the information I have provided is current, true and <br />correc Vthe `best of myVnc`wI;dg`6, and meets the California Health & Safety Code requirements. If the food facility <br />operator fa' to c mply w.4'h the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissa o er shall n iify the immediately. <br />Signature I A IA V_A6 Date - <br />3. To be comp eted_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 <br />Date <br />1868 E. Hazelton Avenue I Stockton, California 05205 1 T 209 468-3420 1 F 209 464-0138 1 wvvW,sjgov.org/ehd <br />