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, SAN$lOAQUINp <br /> Environmental Health Department <br /> SYS , —COUNTY— <br /> J <br /> 1 <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 completesection 3. <br /> 1.To be.cbm leted.� AP1PLICANT:_ - ' <br /> Business Name �M_ � Lic.Plate# 5 31 M Z <br /> Owner/Operator Name - <br /> Business M`ai`ling. Address G <br /> citPh. <br /> Bus. Ph. { �a�(}� Att Ph. <br /> IUt�0.. 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 Cal"rfomia Health & <br /> Safety Code, and San Joaquin Cgunty, Environmental Health Department (EHD) requirements. if the use of the <br /> commissary' d' ti the rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation e <br /> Signatu Datekn (4� <br /> 2. o:be`:. -le-tedb COMMISSARY-OWNER/OPERATOR <br /> Commissary Name L R Ca*1 eC('_i r„k FA# <br /> Address rr.GM �-- "rNfkA4 wit Bus. Phone 01061• 4.1(241 - <br /> City. <br /> .1(241 -City 0�'O[,tGAGvN Zip *I S Zo 5 Owner/Operator (Z\n+p A M e jF <br /> Check all appropriate services provided: <br /> Wastewater disposal �'3 comparbnent sink EI cal hook-ups <br /> (olid waste disposal ® Food preparation T 'let and handwashing <br /> 0"Hot&Cold water for cleaning ®— S/tole refrigerated food able water <br /> 0 Store dry food/supplies Overnight parking ®/Vehicle wash <br /> 1, j 1?,)5 i CGA I G �) Q) hereby state that the information I have provided is current,true and <br /> correct to the best of my k edge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the di ons of is agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify Ii <br /> E I 'mm <br /> Signature Date <br /> 3. Tobe coin let -th NV HEALTH jurisdiction outside of S.an.-Joa tiro 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 /> f <br /> REHS Signature Date <br /> 1868 E-Hazelton Avenue I Stockton,California 052051 T 209 468-34201 F 209 464-0138 1 www.sjgov.orglehd <br />