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'==A <br /> .t � SANlOUIN Environmental Health Departmentartment <br /> ,� —COUNTY— <br /> �} <br /> COMMISSARY AGREEMENT PgDS-4 Fz7� <br /> Mobile Food Facility+ Caterer <br /> Complete sections land Z If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1:.To be.:completed-by APPLICANT <br /> Business Name 9111 Uc.Plate# <br /> Owner/Operator Name <br /> Business Mailing Address �D S <br /> city J' State�Zip `�So2/S Bus. Ph.A97- -J-XI- 21736Alt Ph. <br /> I, tC n tnUWO J-i9� hereby state that the above information is current,yue and corned to <br /> the test of my knowledge and agree to utilize my approved commissary in accordance with Cal'domia 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 enalties. <br /> Signature _ // "y Date, <br /> 2 Tobe>com leted-'b :COMMISSARY OWNER/OPE:RATOR <br /> Commissary Name.L A Ccs CAA c Car FA# <br /> Address n.0IGO E arAAO Bus. Phone 20CI• /tLI <br /> City oyoC,t<.ItcVM Zip Owner/Operator C`ni0 Acne_--t <br /> Check all appropriate services provided: <br /> EI'lWastewater disposal ice"3-compartment sink E cal hook-ups <br /> e ,olid waste disposal fl Food preparation _�T 'let and handwashing <br /> 0 Hot&Cold water for leaning ® Sto refrigerated food PPetable water <br /> fl re dry food/supplies Ovemight parking :Vehicle wash <br /> I. UAWA KRAlA Ez hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,an eets the Califomia Health&Safety Code requirements. If the food facility <br /> operator fails r comply with the ce ons of this agreement, or ff this agreement is modified or cancelled, the <br /> commissa er shall notify the D immediately. <br /> Signatu Date <br /> 3. T,o:be completed.b -the ENV HEALTH:jurisdiction outside'of San.Joa' uin'Go.. <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 />