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OC <br /> SANAOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greotness grows mere. <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 <br /> Business Name &S rllt_52 04Sn a 'A)' Plate# <br /> Owner/Operator Name Alk �kxr ra <br /> Business Mailing Address -+ IS CA(/& <br /> City Gout StaterZip�Bus. Ph, Alt. Ph. <br /> I, ASI m iy. , 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 �� � Date a - C) cJ <br /> 1. 2. To be com leted b comm/ISSARY O/WNER/OPERATOR <br /> CommissaryName C�0 1/I V/Gl/i�N kt fG{vD FA# <br /> Address N'9," S, l0 u t 'e_ I Bus. Phone ZD <br /> City Lgj, !Zip g5t2!(,n Owner/Operator D t Vv <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink O Electrical hook-ups <br /> 13 Solid waste disposal T Food preparation ®'Toilet and handwashing <br /> EA Hot & Cold water for cleaning P1 Store refrigerated food 0 Potable water <br /> FStore dry foo /supplies 17 Overnight parking 0 Vehicle wash <br /> 1, , hereby state that the information I have provided is current,true and <br /> correct to thel best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the c nditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shat n tify the HD imme iately. p <br /> Signature Date <br /> —Tr7 <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 />