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SANJOAQUIN Environmental Health Department <br /> —COUNTY-Greatness grows here. <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 V )'A-PA We- CR-J�—� Y✓1 Lic. Plate# 6 "KQJ <br /> Owner/Operator Name Yeo j �I f Gt n l7 <br /> Business Mailing Address� �� l✓`f �,/2 <br /> T <br /> City S"i`a cK-ra/v State(* Zip q 5 aoo Bus. Ph. It. Ph. <br /> I, , 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 penal ' <br /> Signature �� Date tit <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name CK 1\1 ti u 4 c C-Au!klm FA# y w <br /> n <br /> Address 34 I2k C. rn: ryf_ a Gvc- Bus. Phone �n— SHF - N1tiq a <br /> 7 ro <br /> City ZipsOwrfr/Operator q .M Z <br /> Check all appropriate services provided: 0 ic 0 <br /> Z <br /> Wastewater disposal O 3-compartment sink N\13 Electrical —Electrical hook-ups n m m <br /> O Solid waste disposal p Food preparation '�'Vl Toilet and handwashing > X <br /> n <br /> Q Hot & Cold water for cleaning Store refrigerated food O Potable water N < m <br /> 0 Store dry food/supplies Overnight parking E3 Vehicle wash m D <br /> 3 <br /> I, , 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 -q� ce., --, Date -7--/f/—c�=�2�. <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 />