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S k N J O A Q U I N Environmental Healthepartmen�r <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 a C o �� � � Lic. Plate# QD 3 <br /> Owner/Operator Name U l CTc) (L U A L L2 6 L <br /> Business Mailing Address �'( S, /�y�} tjf: S 4 t) <br /> CitVr `p N State CRZip g Bus. Ph?oc'� �,2 2`13 1-5 Alt. Ph. <br /> 1, V[C k 0 R_ tS R L-A-,7A L 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/OPERATOR <br /> Commissary Name 1 /?)(U 11�/ C/1_T C (� (l� �J�CITY' CES l EP- FA# <br /> Address l7 / 7 S _ U X6(6 v T Bus. Phone <br /> CitySWlbrji 11 Zip 9_5� O Owner/Operator /�A-T <br /> Check all appropriate services provided: / <br /> CVWastewater disposal-compartment sink � Electrical hook-ups <br /> Solid waste disposal Irk Food preparation Toilet and handwashing <br /> 0 Hot & Cold water for cleaning Store refrigerated food i-epotable water <br /> �St r d` food/�s pplies Lj Overnight parking z,w' Vehicle wash <br /> I, 1 ���✓ 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 ownerhal ti t EHD i enediately. <br /> Signature © l Date A 6 2- <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 />