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SANAOAQUINp <br /> Environmental Health Department <br /> COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility # Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT �p <br /> Business Name r-PjkT_r_ R I R r6f-Nt�A01 `rA Lic. Plate#!1(Nk/697 <br /> Owner/Operator Name 6114 Aca/L/9 <br /> Business Mailing Address f 2-91?9 C/ffmp DRIP <br /> Citylua()l6Cr� State Ct7Zip 953 �.,34 Bus. It. Ph. <br /> I, �V ig A(rr-arGt(R L_12 A ,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 it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date �Z132 v <br /> 2. To be completed b MMISSARY OWNER/OPERATOR <br /> CommissaryName U [66&A rfi7(-9/(L(6 %&ClL GE/07Zz9, FA# <br /> Address17 —WIL(ID4 5 L Bus. Pho�Inem` .z ?ff- I4 <br /> City,SfiDC_�Ta�. C <br /> Zip ?5.20to Owner/Operator /IR /Rftpa <br /> Check all appropriate services provided:: <br /> —/Wastewater disposal ES/3-compartment sink Of/Electrical hook-ups <br /> MSolid waste disposal Food preparation IV/Toilet and handwashing <br /> Ul/Hot& Cold water for cleaning 11( ore refrigerated food I Potable water <br /> Storedry food/supplies [3 Overnight parking 12/Vehicle wash <br /> /� <br /> I,r/ AQ V ' 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 EHD 'mmediately. <br /> Signature w� Date 12- 3126 Z- d <br /> 3. To be-completed by the ENV HEALTH jurisdiction outside of San Joaquin 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 />