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E <br /> SAN J OAQ U IN Environmental Health Department <br /> — COUNTY-- <br /> —_- Gre:ltrl Sc �rG tvS �ie: .. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections 9 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 N2meX/04q xony Ike/jU'(VvtS Rp0 Lic. Plate# i'I H FAyl y <br /> Owner/Operator Name / g,?V Yana <br /> Business Mailing Address ((40 ohm 54-,ead1�f <br /> City dam e-s,'Vv State 0 Zip 15, 31� Bus. Ph. 967- 317- /9'9'S Alt. Ph. /V/J <br /> 1, N00�2 VP y' 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 (END) 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 P�enalties <br /> Signature .414 Date <br /> 2. To be corn leted by COMMISSARYrr /OW/NER//OPERATOR <br /> Commissary Name 1��t / L (�-� l FA# <br /> Address ����� s sL/li��h,%U S� Bus. Phone <br /> City �,��� Zip lJ Owner/Operator / ) / <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink fi3 Electrical hook-ups <br /> Solid waste disposal D Food preparation J3 Toilet and handwashing <br /> E' Hot & Cold water for cleaning 0 Store refrigerated food Potable water <br /> 0 Store dry food/supplies $ Overnight parking Vehicle wash <br /> I, Z" <br /> � Pr/ , 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 owners noti the!Eii ediately. <br /> Signature Date <br /> 3. To be completed by t /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 eA/ww.sjgov.org./ehd <br />