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SAN'IOAQUINp <br /> Environmental Health Department <br /> —COUNTY- <br /> - Cir POInusc g,o,}5 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 T.RtNG Ry_IAuifV - J Lic. Plate# <br /> Owner/Operator Name f�( (}fn�r ,F;�t�l✓my) <br /> Business Mailing Address 22(o sown', 0 <br /> City Stat<AzipCls3 b Bus. Pk2-O(j) (gg0-904Alt. Ph. <br /> I, AV6 Joh WIc1Jt1 , hereby state that the above information is current,true and correct to <br /> the best 6f 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 hol r must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p alti s. Z3 <br /> Signati AZ Date <br /> 2. To be.completed by COMMISSARY OWNER/OPERATOR <br /> n� <br /> Commissary Name )/"�/J1 J FA# UY <br /> Address ( �qJ �n� Bus. Phone,,90 '�7 3 <br /> City i S zip Z� Owner/Operator(' � hQS� <br /> Check all ppropriate services provided: <br /> Wastewater disposal C4 3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> Store dry fooS1/suppl'es Overnight parking Vehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correct to the best of rAy 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 /> commissaryyowner shall notify h EHD immediately. <br /> Signature �/ Date <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 vnvw.sjgov.org/ehd <br />