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SAN J Q A Q U I N Environmental Health Department <br /> .-COUNTY <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 n C- o )—o c-b Lic. Plate# D 3 9 <br /> Owner/Operator Name U l C`C (_ S 6 LK2 A L <br /> Business Mailing Address S, /� tj <br /> CitV�C O N State C ftZip g_�f,6 Bus. PhP` '� 9,2 2`3 7-5 Alt. Ph. <br /> I, V t C-l o R_ �s R L .A-,;, A , 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 and penalties. <br /> Signature Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATORCommissary Name J N4(0ILl C� 1 �=6 I t�6 /JOU 6 k CE(UTEP- FA# <br /> Address (7 17 Sr UO M v T Bus. Phone �q <br /> City-1;,Tb_cKl6N{ C 11 Zip �5�� O �, Owner/Operator y <br /> Check all appropriate services provided: / <br /> Wastewater disposal CV--3'-compartment sink °1 Electrical hook-ups <br /> Solid waste disposal LT/Food preparation 17/. Toilet and handwashing <br /> Er-'Hot & Cold water for cleaning M/Store refrigerated food repotable water <br /> dSt r d food/lies L�Overnight parking W- -V-ehicle wash <br /> I, (' �`�✓ hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and meets the Csalifornia 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 ownerhall of t EHD i mediately. <br /> Signatures Date A 2- <br /> 3. 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 />