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SAN. JOAQU Y� (�D`tlFG�[�al"d�iiC��6 :" uJG �a�-1 �� fl Gy6�6 ; <br /> ---COUNTY--- <br /> COMilii SSARY 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 Name R( (,- oDpy's N -S Lic.Plate# <br /> Owner/Operator Name bfi'1 qi W,4(ral>a/L <br /> Business Mailing Address yZ/,3 �H or g/ / <br /> City Md9-eJl� State Zip 53S Bus. Ph. 2011 Y13 gr1494Alt. Ph. <br /> 1,A0 PAID �( 464 ie— ,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 JoagWu County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinpermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penaltie . gg <br /> Signature Date J (F Z <br /> 2. To be completed <br /> b COMMISSARY OWNER/OPERATOR <br /> Commissary Name VG1.1(6111, lA/ FA# <br /> Address_7'tY fkVfil ( r Bus. Phone 2-of L(F3 50?k01 83S 77(y <br /> City L-ScA-Ldal Zip q _3 7-0 Owner/Operator f20n� 14446AIEiL / <br /> Check all appropriate services provided: <br /> Wastewater disposal 13_�3-compartment sink ectrical hook-ups <br /> Solid waste disposal mood preparation 0a"Toilet and handwashing <br /> RHot & Cold water for cleaning '7�tore refrigerated food P"Potable water <br /> E Store dry food/supplies i�Overnight parking Wvehicle wash <br /> I, (2o ( (m/fes 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 comp i e conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner ify the -immediately. <br /> Signature Date It <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 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />