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~ <br /> SAN <br /> | [l � U | N <br /> ��� |� � H4UU / |� Environmental Health Department <br /> '---{�{]Ui"'ITY--- <br /> - <br /> y's=� 6e/� <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility CBf8Pe[ <br /> Complete sections Yand 2 If your commissaty is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed by APPLICANT <br /> Business Mailing Address M2.1 a&0 <br /> 1. 6 Ql(�_,�1� V1_1 15 , 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 Dapartment (EHO) requirements. If the use ofthe <br /> commissary iediscontinued,the permit holder must notify the EHD. Failure tonotify this office may result inpermit <br /> revocation and penalties. <br /> Signature `-~' Date <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 10AI� T^^e <br /> Cit zip 25_2- ()�_ Owner/Operator 1)e_e_Aee CAtiaill wed— <br /> Cheoka|| oppropriateaervicesprovided: <br /> ^' <br /> [3 Wastewater disposal 0^3'onnnpartnnentoink aIE|eotrico| hook-ups <br /> ;/S'o|id waste disposal 0 Food preparation O'fo'i|et@nd handvvashing <br /> E3 Hot & Cold water for cleaning Cl-^8tone refrigerated food U'Potab|e water <br /> 10,-!E�tore dry food/supplies [I-Overnight parking C] Vehicle wash <br /> |. Vherebystate that the information | have provided iocurrent,true and <br /> correct tothe best ofmyknowledge, and meets the California Health&Safety Code requirements. |fthe food facility . <br /> operator fails to complywith the condition�� the <br /> commissary shall notify the E <br /> 8ignoW ~ -- - ' --- --� ~-- a <br /> 13. To be completed by the ENV HEALTH jurisdiction outside of San Joa <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked aen/ioea are available at the <br /> above commissary. Please notify EHD |fthe status uftheir operating permit changes. <br /> REHS Signature Oat <br /> 18S8E. Haze|ionAvenue I Stockton, California Q52O5 | T 209 468-34201 F 209 464'0'138 1 wvw.sjgov.org/ehd <br />