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SAN JOAQUIN Environmental Health Department <br /> �J I . <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 )y APPLICANT <br /> Business Name[ I b ( 1.a't5 I'� : Lic. Plate# Q <br /> Owner/Operator Name -AIDPi Arl�-Pl P( Cln j <br /> Business Mailing Address lj lit- '1 l � r <br /> City �/M�I�[__(�i�l StatepA ip RLJ�Bus. Ph. '90132 6— Alt. Ph. 5/C)' �j 5'—qj* <br /> I, (An21Vr-4 P t G%-CEJ(') , 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 and penalt <br /> Signature � Date t1 l � Z�� <br /> i <br /> 2. To completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name � � FA# <br /> Address"[ f�L� Bus. Phone_SZ7 ,,Wl Or'r�0 <br /> Cityfid a. rAl -l C.- Zip�Owner/Operator D,,.,,t <br /> U / <br /> Check all appropriate services provided• �/ <br /> wastewater disposal n3-compartment sink 61 E lectrical hook-ups <br /> waste disposal 0 Food preparation T ilet and handwashing <br /> Vot'& Cold water for cleaning Q tore refrigerated food VPO able water <br /> Ll Store dry food/suppr,lies ;j Ovemight parking C3 Vehicle wash <br /> ej y��t hereby state that the information I have provided is current,true and <br /> correct to the best of mylkhoMedge,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 notify th(a EHD immediately. y <br /> Signature_ Date <br /> 31. 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 lealth & Safety Code. The above checked services are available at the <br /> above commissary, please_ notitpi EH i the status of their operating permit changes. <br /> REHS Signature V t/�y/J/�I/1 Date ' a ' 9 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 TT 2 -3420 1 F 209 464.0138 1 www.sigov.org/ehd <br />