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SANAMUIN Environmental Health Department <br /> 4U.1 - —CC)'JNTY-- - <br /> r. <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. Tobe cOri leted:b Y. APPLICANT <br /> Business Name r- 'k U.r-i n.rr Lic.Plate# aL 3 ES5,& <br /> Owner/Operator Name i fir. - Q 2� <br /> Business Mailing Address <br /> City Th f A 0 X State('Zip 61 Bus. Ph.(�(XI <br /> I,Qff jo i rr,A A tVj d f 11,-) a� l a, hereby state that the above information is cucrent,true and correct to <br /> the bestlof my knowledge and agree o 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 END. Failure to notify this office may result in permit <br /> revocation and penal'es <br /> Signature .(n � Date 0�oo _ <br /> 2e To beborh feted by COMMISSARY-OWNEWOPERAITOR <br /> Commissary Name L A CQ rnp.c c% rA� FA# <br /> Address c.GIM S_ "barky i; t Vk Bus. Phone /t 16 44 - <br /> City��US Kkan Zip X15 Zoe Owner/Operator Cin: A cne- t <br /> Check all appropriate services provided:: / <br /> Wastewater disposal 1103-compartment sink :E;4ctrical hook-ups <br /> -/olid waste disposal 13 Food preparation T�ailet and handwashing <br /> i Hot&Cold water for cleaning ® Store refrigerated food f>–aJP' able water <br /> 13 Store dry food/supplies Ovemight parking Vehicle wash <br /> 1, 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�K 1 ,)Ik 24 /� Date <br /> :3. Tobe,corrip_leted-by the ENV HEALTH 'urisdiction outside of San:Joe 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 952051 T 209 468-34201 F 209464-0138 1 www.sjgov_or91ehd <br />