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SA6JOAQUIN Environmental Health Department <br /> 11 COUNTY <br /> ctlP Greatness 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 UV(f L e- T/t,e J5;�S wY-- Lic. Plate# �/ . Z b g 2, <br /> Owner/Operator Name 12errY <br /> Business Mailing Address POO 3051M <br /> CitStateC A Zip rSZ 3 Bus. Ph. ZOfJ-662 -1C)bI Alt. Ph. <br /> I, y'?e_ CC,2zer- , hereby state that the above information is current, true and correct to <br /> the best 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 penal 'es. <br /> Signature '"� �'- Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name (,{/U'(()g) C)I (N G h'U.cK Cc(6-TO, FA# <br /> Address 17 17 J. UN1l o r J`t Bus. Phon4�1 C 9 '� r c� <br /> 5-,5-q( <br /> Cit ys�c)c�T_ 7J, (A Zip gS 2 O 6 Owner/Operator�l <br /> Check all appropriate services provided: <br /> 01fNastewater disposal L'-3-compartment sink Electrical hook-ups <br /> C-Solid waste disposal Food preparation Toilet and handwashing <br /> CVfiot & Cold water for cleaning Store refrigerated food Potable water <br /> tS Store dry food/supplies Overnight parking L�Vehicle wash <br /> I, /MT 1(#')(r 6 0 , 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 <br /> commissary owneryhal�notif t mediately. <br /> Signature ' Date <br /> F 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 />