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SA N J OAQ U I N Environmental Health Department <br /> —COUNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 9 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 jA1 6/1 j61kRIR &) flC& ,tV_ Lic. Plate# 3z35Sg3 <br /> Owner/Operator Name CIVNIQUc OP©mcgz <br /> Business Mailing Address 5.3 7 1i), TTS 5-1 <br /> City6lbe 14 StateCA Zip6 Bus. Ph(2095181-2fS7 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. <br /> Signature Ylt c ��„M E_V v Date (/�✓° /1 C, 2- <br /> 12. <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 616'tP rti C_d(cfernl6 A40 r t>y 1'tA FA# <br /> Address 17/7,5. aA!(Od 1— Bus. Phon 1z`i <br /> City 7/ aTZ)ILt, ipiJraLG Owner/Operator do, I %Ie dl) <br /> Check all appropriate services provided: <br /> [y(Nastewater disposal a 3-compartment sink 13Electrical hook-ups <br /> EIS'olid waste disposal la_�ood preparation 13 Toilet and handwashing <br /> CrHot & Cold water for cleaning CYStore refrigerated food IE(Potable water <br /> ETISnntore dry food/supplies Overnight parking U Vehicle wash <br /> I, 1'7 R� / /!tl{�QU 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 owneer..srall t phe E immediately. <br /> Signature Date <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 />