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SAN. )O A Q U I N Environmental Health Department <br /> _..._� <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 7_fi C 1'=% 6� 101*/�lejlvo Lic. Plate# <br /> Owner/Operator Name �/� �� PW00k <br /> Business Mailing,,,,//Address �J�� � ��/elff sr <br /> CitySr"U�G>�e/ur Cf>ZState Zip �sG� Bus. Ph. �dg=3`� Alt. Ph. <br /> I, if�2n1e:S�T_c )kfi,1)6X 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 5—`/-2/02- y <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UlkJOAl G/f 7-ckI N6 _1_kILCk CS R FA# <br /> Address U/ 7s,, a4J(oA ,ST-, Bus. Phone <br /> City5_6cKnA cyt Zip2'S'26 h Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 0/3-compartment sink M/Electrical hook-ups D <br /> Solid waste disposal 'Food preparation �/Flotable <br /> Toilet and handwashing <br /> [34Hot & Cold water for cleaning F- Store refrigerated food <br /> water <br /> IL.Y Stored food/supplies lies E.11'Overni ht parking wash <br /> dry PP 9 P g <br /> 1, Ak1_r f ( R RIO U , 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 own sha if he EHD i mediately. <br /> Signature Date 1'�2J / <br /> 0 a �} <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 />