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SAN J Q A Q U I N Environmental Health Department <br /> - c o u N T Y-----.. <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 <br /> rd b APPLICANT <br /> � <br /> /U <br /> Business Name / >q e2 14ef Q Lic. Plate Of Zfo R 1 <br /> Owner/Operator Name R P U L P5AE Z <br /> Business Mailing Address '5y/ . <br /> '.5, �124 Zj <br /> 19 <br /> City 5'OcKT6 State CA Zip q-5_.20Bus. Ph OJ513 n38 <br /> I, RAS _ P6982!- -�O U C--S 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 andpJV',g;enalties. <br /> " `� <br /> Signature� �� .�C/ _. Date 3h01202_6 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UpJfwM-6pgpl� O`( e- rEr� FA# q <br /> Address 1 7 /7S , U1U1 V �, Bus. Phone D -2, f �` 5 q <br /> City S C_(�T� �, { Zip %S C� Owner/Operator lli 1Q <br /> Check all appropriate services provided <br /> [a/Wastewater disposal 3-compartment sink 13 Electrical hook-ups <br /> LySolid waste disposal Food preparation IToilet and handwashing <br /> CO/Hot & Cold water for cleaning 13/-Store refrigerated food Notable water <br /> Store dry food/supplies Or-ol vernight parking M-Vehicle wash <br /> I, 9 k7- R 14 A v 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 modifiedor cancelled, the <br /> commissary owner all notify the EHD i miate)ed <br /> Signature Date- 0 2 cj <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />