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,PauiN c <br /> SA N k` OAQ U I N Environmental Health Department <br /> �� ' ---COUNTY <br /> c4c�FoaN'P' Greatness 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 NameA/h Lic. Plate# 71 <br /> Owner/Operator Name a 1A 4 no <br /> Business Mailing Address CSC <br /> CityQ Cc[ State Cat�Zip aBus. Ph J- ��, 7�U � Alt. Ph. <br /> 1. 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 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 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name !` (,OJ4 JIi5,�Y-A)r% FA# <br /> Address �o Zee 5 S4 q5 2e/© Bus. Phone 70 11 -112- 3 5 7 <br /> City Lo 0" Zip 95Zyo Owner/Operator pir—ikoirU 661eel <br /> Check all appropriate services provided: <br /> Wastewater disposal E3 3-compartment sinkEI ctrical hook-ups <br /> [3 Solid waste disposal [3 Food preparation Toi <br /> Nr let and handwashing <br /> Hot & Cold water for cleaning la Store refrigerated food 1 potable water <br /> Store dry food/supplies Overnight parking 0 Vehicle wash <br /> l , 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 <br /> the EHD immediately. <br /> Signature � �`7r Date <br /> 3. To be completed by the 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 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />