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" 1 SANAGAQUIN Environmental Health Department <br /> l —COUNTY— <br /> \1- Grectness 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 com leted by APPLICANT <br /> Business Name 14 W UCA P$4 £ r9_A97_ Lic. Plate# <br /> Owner/Operator Name A5W j clp <br /> Business Mailing Address 84 (Q 7[eCAS6rjCE ,4 UE <br /> City--:;C?�p ,*N State4'Zip Bus. Ph. Q_ 6F 71 7 t. Ph. <br /> I, 17d dlt >� 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 Califomia 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 penal ie . <br /> Signature Lit Date <br /> 1.2. To_ be com lete�dl b COMMISSARY OWNER/OPERATOR <br /> __ 4� <br /> Commissary NameZ1-LC FA# <br /> Address 676 �� 5GICK.1-I°61-6 5k- Bus. Phone <br /> City �! Zip q S 'c/I Owner/OperatorrGril s'� D�ytor <br /> Check all appropriate services provided::E <br /> /Wastewater disposal 3-compartment sink Electrical hook-ups <br /> M Solid waste disposal 13 Food preparation Electrical <br /> and handwashing <br /> @�ot& Cold water for cleaning M Store refrigerated food allp"Otable water <br /> [✓Tore dry food/supplies U Ovemight parking M Vehicle wash <br /> 1, ��rfq l rd n lln�r , 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, orf this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> Signature---�� �A <br /> Date_ .3 _a to --ZB7iJ <br /> 3. To be com leted b the ENV HEALTH 'urisdiction outside of San Joaquin Co. <br /> The commissary is located in <br /> commissary requirements in Califomia Health & Safety Code. The above checked–�CountY- The bove services ervcesoareacility av able at the <br /> ts the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature <br /> Date <br /> 1868 E. Hazefton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />