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Environmental <br />r,fre.35 grc;c,fs. faerc. <br />(OMMSSARY AGREEMENT <br />Mobile Food Facility* Caterer <br />Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />`I. To be compleied-by APPLICANT <br />Business Name <br />Owner/Operator Name <br />y.t®`Lyq. 1rF- <br />Business Mailing Address X3`'1 nn �{ <br />City A��� /Statue C -A- Zip �'��3(3 Bus. Ph. �f ` � Alt. Ph. cA -Ir-3t / r <br />I, 7-1 f�L` 7 , 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 />i� <br />Signature .o. G�� /d%2 Date <br />rvl Lic. Plate# '' V-)(C_aAU <br />p <br />2. Ta be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name t \ C_ 5y` Gc GJ C.' ic cact RC1') FA# <br />Address 3u{ I'k L-� (11 i N F_ R M L; Bus. Phone ` occ - <br />"` <br />City S`ro csC?-6 / ZipCyl- 5'�cp Owner/Operator <br />C itv <br />Check all appropriate services provided: <br />0 W� z <br />D Wastewater disposal D 3 -compartment sink Electrical hook-ups <br />0 <br />D Solid waste disposal D Food preparation Toilet and handwashing <br />z Z - <br />D Hot & Coldwater for cleaning _A3 Store refrigerated food D Potable water <br />C) M 1 1 <br />D Store dry food/supplies � Overnight parking D Vehicle wash <br />to 0 <br />I, hereby state that the information I have provided is current, true andN m <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facilitycD <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, <br />the <br />commissary owner shall notify the EHD immediately. <br />Signature ��i-r,��..,.Y, �'� ' Date "7 --2--`��`� <br />3. To be completed by the ENV HEALTH jurisdiction outside of San JoaquinCo. <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 <br />Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.orglehd <br />