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SQNdQQQUIN Environmental Health Department <br /> —COUNTY— <br /> c_: <br /> Greotness 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. l <br /> 1 . Tobe completed by APPLICANT / '/ <br /> Business Name f IAA A /IAA/ S No 41 /'o e�E •kE <,2EAm.&-ic. Plate# 2, 16I Y <br /> Owner/Operator Name Lo <br /> Business Mailing Address G6 t —'V Z 7i <br /> citycityTeAfu Statee-4-zip��3x_ PF✓ � 65167 Aft. Ph. <br /> I, od , 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 Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, e e it older must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date 0,3 15 26 <br /> 2. Tobe completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name P C Ci b O �, C'Rg 1A M FA# <br /> Address 3 LA\'k C. ml N E AY E Bus. Phone 2001— QHP %_.ti9 <br /> City ST o C k ?o N CH Zip q S" S Owner/Operator � <br /> 4 0 <br /> Check all appropriate services provided: 0tV A <br /> [3Wastewater disposal E33-compartment sink Electrical hook-ups � m Z <br /> ❑ Solid waste disposal ❑ Food preparation )'R Toilet and handwashing 0 jC 0 <br /> Z <br /> ❑ Hot & Cold water for cleaning "E% Store refrigerated food ❑ Potable water RZI t7 <br /> [3 Store dry food/supplies Overnight parking ❑ Vehicle wash D X 0 <br /> I, hereby state that the information I have provided is current, true and co <br /> < Z1 <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility C MD <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the tT <br /> commissary owner shall notify the EHD immediately. <br /> Jcx <br /> Signature zna. 2D264!/ m.. Date <br /> 3. To be completed by the ENV'HEALTHjtarisdiction outside of.San Joa -uin 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 />