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SAN JOAQUIN Environmental Health Department <br /> _ <br /> —COUNTY— <br /> 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 U <br /> Business Name A A<U S C o j I'l AZ kC`/a N Lic. Plate#_3 Lq 1 �6 y <br /> Owner/Operator Name tl 0� C D�- T <br /> Business Mailing Address 76 S d ZA2K ( �- , <br /> City �j�Ocll�r'orJ State`A Zip 8521 �_ Bus. Ph.Z0 Q0NEj Alt. Ph. <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. 1 Z 9 <br /> Signature 7n S P d n P Z Date l L_ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name (� 'Ilq)fnu.. t�f_ )-er,ith SvPig L, FA# <br /> Address 'f �JU S, As r j2o ' Bus. Phone 2 c� <br /> City S I n c V- La rx Zip Q,92 G l Owner/Operator hf-ix_ �ti ZJ c <br /> Check all appropriate services provided: <br /> 0-fNastewater disposal 13-3-6ompartment sink OrElectrical hook-ups <br /> El Solid waste disposal Or"Food preparation �dToilet and handwashing <br /> D'Hot& Cold water for cleaning 0/Store refrigerated food 13"Potable water <br /> tore dry food/supplies I:2/Overnight parking O'Vehicle wash <br /> I, S QU lr,.',� , 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 noti the EHD immediately. <br /> Signatures Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa 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 95205 1 T 209 468-3420 1 F 209 46,1138 1 www.sjgov.org/ehd <br />