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S � Q(�QQ , Q Environmental Health Department <br /> _ C O iJ NT"---- <br /> COMMISSARY <br /> T"____COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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 APPLICANTII <br /> Business Name >apa i .Saw Qdnrc_c,r ,i Lic. Plate# <br /> Owner/Operator Name() �_ (�1l1'L11 (�tCT r61. <br /> Business Mailing Address <br /> City KfOKState C.AEip Bus. Ph. Alt. Ph. <br /> I, Re C'J-Vk 'r3C4ftCfirC1, hereby state that the above information is current,true and correct to <br /> the b st 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 e Ities. g <br /> Signature Date to/z a'lZoe--Cs <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName ( y�lrW VLIs� rfrt� SV �/ FA# <br /> Address A1!'iyor-� Bus. Phone ZC)V— S^b � <br /> -Citzip (9SZ 0,L Owner/Operator Aft:) <br /> Check all appropriate services provided: <br /> V. <br /> —� /�Wastewater disposal t°�3,-compartment sink t:�ectrical hook-ups <br /> C?'Solid waste disposal= Cd/Food preparation ,,./Toilet and handwashing <br /> C"Hot & Cold waterfor cleaning L�!Store refrigerated.food La Potable waterL- <br /> JL�Store dry food/supplies" I Overnight parking U/Vehicle wash <br /> ['�. I R. � &CjC.�) , hereby state that the information I have provided is current, true and <br /> correci 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 E mmediately. / I <br /> Signature Date wZ2 Iv / _ C1 <br /> 3. To be cpm feted by the ENV HEALTH udsdiction outside'of Sari 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 /> 1863 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 vAAv.sjgov.ore/ehd <br />