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SAN ) Q A Q U j N Environmental Health Department <br /> COUNTY— - <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. To be completed by\APPLICANT 1 ' <br /> Business Name 3 0\m%r,I U i NO r-c CWC'mav!, Lic. Plate# H N <br /> Owner/Operator Name &c0 i � 1c Qip�trecllc� r�C�11) Ci <br /> Business Mailing Address Q9 t -3 N' -T"c' cv cel' <br /> City i'(eli StateCci Zip t}S3)i� Bus. Ph.D()C9 933 0'�--00 Alt. Ph. CiU Cl -:J�- I(7C q <br /> I, 0.b f i P do Pl • rY1ct �-hctcc— , 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 a dd penalties. <br /> Signature .Y�i�^ is L -�Y� ��s �C� Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name JO�t� r1n14 C�"n-Pf ACCec'-meFA# DDO30Lq <br /> Address �3 tU t ra ct' t3 l v A Bus. Phone Q O ri 2 3�) 016 yO <br /> City '\('a Lj Zip 15 3 7�a Owner/Operator Cha b r e w N-A( Ji.r< ,l <br /> Check all appropriate services provided: C(kra I J, .a <br /> Wastewater disposal 3-compartment sink Electrical hook-ups <br /> 0 Solid waste disposal Food preparation �Z Toilet and handwashing <br /> -krHot & Cold water for cleaning ;(`V Store refrigerated food kPotable water <br /> Store dry food/supplies C Overnight parking Vehicle wash <br /> 1 clb i'i ack rN dAU['c, 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 /> commissa�"�ler shall notify the EHD immediately. <br /> Signaturel.(.J '1c&Ai &7 MaZLk,' 6' Date <br /> 3. To be completed by the ENV HEALTH jurisdiction 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 />