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SAN JOAQUIN Environmental Health Department <br /> COUNTY- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 t <br /> Business Name N',��K t iS C f e a�t — 3y till Lic.Plate# <br /> Owner/Operator Name 50�moy) 4 <br /> Business Mailing Address 2S 4� W�e,�`+ &e vJe S <br /> City Sa ar.k u�State UgZip�iS Bus. Ph.(20)3�1�� 5-35-1 Alt. Ph. ILc� <br /> 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 current,-true <br /> 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 7 21 Z 0Z G <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name Lu— (.o✓h e i"C,,�-Lk FA# II <br /> Address G0 Bus. Phone 206 <br /> CiK Zip 05 wnerlOperatorA fyi4L r <br /> Check all appropriate services provide <br /> d: <br /> fflWastewater disposal 'rat 3-compartment sink 13ectrical hook-ups <br /> Solid waste disposal 1=1 Food preparation fl Toilet and handwashing <br /> f(Hot&Cold water for cleaning E3 Store refrigerated food [2rPotabie water <br /> 1t Store dry food/supplies t- Overnight parking i Vehicle wash <br /> I, Cay\rn, i f w'V\Gvn�f 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 /> 7 <br /> Signature � Date C) �' Gy � U <br /> 3. To be completed fhe 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 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />