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SAN 10 A Q U i N Environmental Health Department <br /> ---COUNTY- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT /n� <br /> Business Name u c <br /> v /ogVtGt t7 ..� l Lie. Plate# -Z/ <br /> Owner/Operator NameA• wA A\�V A I1 YL�D V 1 �_Ct 60, A (17 YL,5 D <br /> Business Mailing Addressj7;�U v%d 5Pn�y\ L�� Y <br /> City{i}�C1�►1 State ZipC Bus. Ph If !n-Z&,/, Alt. 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 alifomia 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 Datea7- Z/'�,7,/? Z.,O <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR • <br /> Commissary Name1 G Cb0ACCa(,a� FA# <br /> Address L�GU 4Lv,,- tw 'n!G Bus. Phone-JVQ� <br /> City Wit „ Zip ' zA 0 ; O ner/Operator <br /> Check all appropriate services provided: <br /> vT <br /> astewater disposal 3-compartment sink 13 Electrical hook-ups <br /> _'olid waste disposal ❑ Food preparation td Toilet and handwashing <br /> Ef Hot& Cold water for cleaning ❑ Store refrigerated food CC�VI otable water <br /> E3 Store dry food/supplies 13 Overnight parking UYv ehicle wash <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 <br /> �oy/ne�r_s�h�allllnpotifyth1�,2, <br /> Dimmediately. <br /> Signature i�.11�Wt�l/`XA� Date t� 1' U <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 />