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SAN IOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Lid pYS. <br /> �r<ntr•ecs urov,: he-e. <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.'kTo'Wcompleted,by'APPLICANT_' ! ". �' ,il ' ;. 4.�r:, : ! <br /> . � <br /> Business Name A E P ^7 Lic. Plate# <br /> Owner/Operator Name A mA R 5, 1 j G H <br /> Business Mailing Address /0 Q I I&I V)R,rJ 5, Ds -I <br /> City MAN i C4 State_O_Zipy533T Bus. Ph.�Qq-q5( 0/_-- Al;. Ph. 4 09- 156' 5,9,.5 <br /> I, 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. 9 1 <br /> Signature //V Date <br /> 2.'-To:be,d6hipleted:by COMM ISSARY,.OWN ER/OPERATOR;_= <br /> Commissary Name P 1 CK A/ ,o 9<,f cg p m FA# <br /> Address—3 q Ia k-' . M( rJ G A 61 V(= Bus. Phone -1 ca0 <br /> Oh x <br /> City S70 cK T n/ Zip ch a SaoS- Owner/Operator 0 N Z <br /> Check all appropriate services provided: -� Ir O <br /> ® Wastewater disposal 0 3-compartment sink � Electrical hook-ups Z Z O <br /> C7 <br /> E3 Solid waste disposal ® Food preparation Toilet and handwashing D M m <br /> M Hot & Cold water for cleaning \Na Store refrigerated food © Potable water < x <br /> 0 Store dry food/supplies `»l Overnight parking E3 Vehicle wash p M y <br /> I, hereby state that the information I have provided is current, true a(A 3 <br /> nd <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 EHD immediately. <br /> Signature . �,v�„� � Date /:l- <br /> 3..To be"completed by We 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 209 468-3420 1 F 209 464-0138 1 www,sigov.org/ehd <br />