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SAN .J QAQ U I N Environmental Health Department <br /> _COU N'T'Y..___ <br /> G ... <br /> F. <br /> ea ries5 grows here. <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 Cf�S 6 L _ II "'e r" Or- t j i nQ je5 Lic. Plate# l C- (o2-30 2 <br /> Owner/Operator Name 6(� A�)l) M A R t 4 M� 6�LL616_33 <br /> Business Mailing Address 13 ( � G�HN A 4AI <br /> City Mfi� 1 �CA State_L&Zip 1�E3�6 Bus. PhLg"9 Z7,S-O.S'/0Alt. Ph. <br /> I, , 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 d' continued, the per Ider must notify the EHD. Failure to notify this offiresult in.permit <br /> revocation andf enolties. 7 <br /> Signature ce may <br /> ' Datez,,?, -d <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name U1L110 fd C_PTE7-PWJG %ki,(L-k CEn11_68 FA# <br /> Address 17 17 S - UN(Q� S-11 Bus. Phone �2 D 9 7 -2 9,? --S_�l` C <br /> City S_JoCka(� , GIS Zip 95 6(�_ Owner/operator 6R-T-- <br /> Check all appropriate services provided: <br /> 133�wastewater disposal 0 -compartment sink i'"Electrical hook-ups <br /> Solid waste disposal C r' ood preparation E3 Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food !/Potable water <br /> M Store dry food/supplies 0-1/overnight <br /> /Overnight parking Vehicle wash <br /> I, I�X l jr R e 0 , 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 owner all notify the EHD immediately. / <br /> 02. <br /> Signature G/� %�=-- ��� Date �. <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 />