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SKJOAQUIN Environmental Health Department <br /> 1-1k -- COUNTY <br /> r <br /> COMMWARA 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 co 5 /a- �b vVy , yS/z V j4j/S t'6 Lic. Plate# 3S3P__f�3 <br /> Owner/Operator Name 4R70190 CAclo,vgC <br /> Business Mailing Address q %GAlOcdi✓S i / t� .9/4A l . C� <br /> City 512C ki—oy State C.r Zip 95-)03— Bus. Ph, Alt. Ph. au 9' y,4 v> <br /> I, 04t , 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 �e20 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name A ("jrn o, � FA# <br /> Address ; Ci Bus. Phone <br /> City ';�o Ly_�\Ck-\ Zip Owner/Operators �'Q Z <br /> Check all appropriate services provided: �� <br /> wastewater disposal 3-compartment sink 4T Electrical hook-ups <br /> la<Sclid waste disposal E3 Food preparation 4Y 1 ilet and handwashing <br /> 6J Hot & Cold water for cleaning M[2Store refrigerated food 13 Po ble water <br /> i13 Store dry food/supplies 'OStvernight parking ehicle wash <br /> 1, cu&eyejmlaAe'2 , 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 /> commissar owner shall notify the EHD immediately. <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin. 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 />