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SANJOAQOIN Environmental Health Department <br /> l" <br /> v'..g <br /> —COUNTY---here <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t Caterer <br /> Complete sections 1 and 2. if your commissary is located outside of Sart Joaquin County also complete section 3. <br /> 1.-Tobe_com ,leted-b APPLICANT . <br /> Business Name N <kl `S ('lreAft ' – Vic,ii Lic.Plate# <br /> Owner/Operator Name Sp'�\Aa-yl Irt i l <br /> Business Mailing Address lS} - - <br /> City S Dr � State agZip�K� Bus. Ph.(260311) Alt. Ph. tL65 <br /> I, CiU �O n7 �} sYl hereby state that the above informatit <br /> on is current, rue 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 penalties. <br /> Signature - Date 2.1 Z 0-2 <br /> 2'To be com feted-b ,COMMISSA-R1`Y OWNERIOPERATOR <br /> Commissar Name � Co&%erC� FA# I <br /> Address 60 H(nA Bus. Phone '?601 <br /> Ci0 weer/Operator A %rvl •f <br /> Check all appropriate services provided, /// <br /> Er*astewater disposal ; 3-compartment sink �ectrical hook-ups <br /> Solid waste disposal (3 Food preparation Toilet and handwashing <br /> dl-lot&Cold water for cleaning ® Store refrigerated food Ur Potable water <br /> 13 Store dry food/supplies 0 Overnight parking E Vehicle wash <br /> I, c" Ghyt, e fnd ✓t&e'Z– ,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 E D immediately. <br /> Signature Date l �' 2C) <br /> IV <br /> 3. To be completed-b"fhe ENV HEALTH 'urisdiction outside of San-joa o'in 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orNehd <br />