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SAJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> °�i� Greotness grows here. <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 <br /> Business Name fL 47- (?tel(C �?ff Q Uc. Plate# U�'A/ 1 3 G y <br /> Owner/Operator Name At K-er g ike <br /> Business Mailing Address <br /> city l- 06-e" State (-i Zip 9Y_)-W Bus. Ph._�oq 3,27 1WAlt. Ph. <br /> I, , hereby state that the above information is current,true and corned 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 pe al ies. <br /> Signature s-" � Date / 0 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName �P� �drvtm :S 7LlA", FA# <br /> Address (c7_/-) Bus. Phone � oq 7,Aq V41 <br /> 0 <br /> City L-6 Zip H5ZY0 Owner/Operator �� ,cvfly DGvwr , <br /> Check all appropriate services provided: <br /> Wastewater disposal 011:-Compartment sink �ectrical hook-ups <br /> C�I, 6�olid waste disposal 0 Food preparation oilet and handwashing <br /> yVrlot&Cold water for cleaningZternTight <br /> refrigerated food otable water <br /> tore dry food/supplies parking Vehicle wash <br /> I, 1 Jtjn4vt,'S 7W�Z+V_Gt_ ,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 the EHD immediately. <br /> Signature 44'd4eff� 1.G11_ Date /'e) '-m —ZOO <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 />