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SAN JOAQUINp <br /> Environmental Health Department <br /> --C Q U N 1 Y__-- <br /> _ �reurness �ro4-••� l,er_. <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 0' f)0 GS Lic. Plate# <br /> Owner/Operator Name DSC R K LA44 S.� bLLO LA <br /> Business Mailing Address 37A7 (--0)( CI,C-CK &6 <br /> City,gTi)cWrJtir State lA Zip 9Y2l 6 Bus. Pt'-) 2 Z t Alt. Ph. <br /> I. (05 c (_ puw f-ft 1 5P, , 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, th ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Da_ ate , ��7/2 c�� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UOLOY6 CR1TfZ1(�GTP_(iCV, C�&-k FA# <br /> Address 17/7 ,5 , u�g(d gal S"T- Bus. Phon4ZI->`6 2 __ q1 . <br /> City '_C KT0_1Ll CA Zip ����� Owner/Operator &T Ilea() Q <br /> Check all appropriate services provided: <br /> Wastewater disposal L4 3-compartment sink TM Electrical hook-ups <br /> Ky Solid waste disposal eFood preparation L Toilet and handwashing <br /> ;rhl//Hot & Cold water for cleaning C$"Store refrigerated food LVII/Potable water <br /> f//Store dry food/supplies crovernight parking Vehicle wash <br /> I, &T 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 owneysh" no`• y the e D iTmiately. <br /> Signature � Date <br /> 7 2- <br /> F3. <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 v.,-wY^,,.sjgov.org!ehd <br />