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`5 A N f Q O U I N Environmental health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections 7 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 NameRpp� Lic. Plate 75 60i 1 Z <br /> Owner/Operator Name •1© � /ti <br /> Business Mailing Address YM9 N 114; t <br /> Ci-t-�ty SRO(; (CJIU State Gfi Zip %Jz� � Bus. PhCo.,b Q.9"70 -C((,3 All. Ph. <br /> ,f' oe �. i A l R UG R& , 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 /> Safely Code, and San Joaquin Count Environmental Health Department (EHD) requirements. If the use of the <br /> commissary isdgtgEtinued. the pe i older must notify the EHD. Failure to notify this office may result in permit <br /> revocation an p)al es. " <br /> Signature - Date /��l2.Za <br /> 2. To be com lete7 by COMMISSARY OWNER/OPERATOR <br /> Commissary Name U11I ( D id IRUCc (:C,0EP, FAQ <br /> Address t117 -$. 1aleyo) �5T' Bus. Phone/ ZrT)�a2(' --5-VA9 <br /> City l'EC fD2rd Zip g Owner/On <br /> perator /7� I I Ude) <br /> Check all appropriate services provided: <br /> V;-?'Wastewater disposal 11/3-comp2rtment sink VEElectrical hook-ups <br /> T'Solo waste disposal U"lood preparation [V I oilet and handwashing <br /> I,VHot & Cold water for cleaning F_4 Store refrigerated food r'�otable water <br /> 9 Stoore dry food/su plies 1:111Overnight parking 04ehicle wash <br /> ,ry <br /> I; r e/ elf �'a� 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 <br /> shall - Dim diately. (� <br /> Signature Date 20 L Z G <br /> 3. To b� 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 /> I SC6 E. Haz.;lton Avenue I Stockton, California. 95205 1 T 209 46E-3420 1 F 209 464-0'138 1 www.sigov.org/ehd <br />