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SAN�IOAQUIN <br /> Environmental Health Department <br /> —COUNTY-- <br /> "sa,r,,,::a.�` Ire Citness caro rv, rare. ® © �p <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 r11 co 5 )a- 'D 9ya- 1411sco Lic. Plate# 3S322..3a3 <br /> Owner/Operator Name AR70A9 CA,'WOAifc <br /> Business Mailing Address A jF c,ol.'OsdWJ / P3'/ 6y <br /> 9 MAiL . w/7 <br /> City 5 Z�ck;ov Statec/I Zip SSaoT� Bus. Ph. Alt. Ph. 2u9' 'g0 P/09 <br /> I, 056� 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 'com ( Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 1A. (1)`M -(( , CA \ FA# `\ <br /> Address .4c1oC) l 1w \ n c t.,r i'i — Bus. Phone C L C C[ v <br /> City ZipCj 4�jo) /Owner/Operator f �` <br /> Check all appropriate services provided: a/ <br /> Wastewater disposal 3-compartment sink GT EEllectrical hook-ups <br /> mSclid waste disposal 13 Food preparation ilet and handwashing <br /> clHot & Cold water for cleaning �❑� Store refrigerated food l3. Po ble water <br /> ❑ Store dry food/supplies t�'Overnighl parking Vehicle wash <br /> I, (�44tp e /y"I e7' , 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 shall notify the EHD immediately. <br /> Signature Y Date (0 - <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 />