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SAN J 0 A Q U I N Environmental Health Department <br /> —COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections f 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 iZeye E- p u pu ser, a ggG(C���4 uc. Plate# �e9;3 Z / <br /> Owner/Operator Name ES // /Dc e Sly S' <br /> Business Mailing Address /-/F J o • <br /> City!&Cklc4,? State C( ZipgS21Z Bus. Ph.ZLIt. Ph.L09- 32-7 �OIfc, <br /> I, ice' /�fc�� , 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��/"2-Ao" -) Date d Z. ",;7 - 2-02G <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name11 FA# <br /> Address S4 4 e Jt Bus. Phone <br /> City Zip_ _()(11) Owner/Operator Li L:'! 6L� <br /> Check all appropriate services provided: <br /> IX Wastewater disposal ❑ 3-compartment sink Electrical hook-ups <br /> .P Solid waste disposal ❑ Food preparation IU Toilet and handwashing <br /> J9 Hot & Cold water for cleaning ❑ Store refrigerated food q Potable water <br /> ❑ Store dry food/su�jplies P"Overnight parking Pr Vehicle wash <br /> / '�/n/G`:r� hereby state that the information I have provided is current,true and <br /> correct to the best of my Wwledge,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 ownershall nngt�fY D immediately. C <br /> Signature �C//�7/1 r; laves ' Date , .�7 '�� & <br /> 3. To be completedg fhecompleted 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 />