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SAN JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> . . . Greatness e^�>v; 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 b APPLICANT <br /> Business Name L rr , kL, I q Lic. Plate# 6 S 0 <br /> Owner/Operator Name kkGa rrcc()o CnU_(G-�n ee <br /> Business Mailing Address � I} K Q cccictvi9 Lv\Y X �Y <br /> City Li StateLLZipS Bus. Ph.tM) _�AZ —�GY#- Alt. Ph. <br /> I, n" - 4 , hereby state that the above information is current, true and correct to <br /> the best of 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 anden Itie . <br /> Signature /C V ( vL Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address (r L rw. h i Bus. Phone 6'4) Z' `ef '�C3 SW <br /> City Lr Qt Zip '1 i t 16 Owner/Operator Al2,yPAA 0 ;14" <br /> Check all appropriate services provided: <br /> M4astewater disposal 97 3 compartment sink CV Electrical hook-ups <br /> 0 Solid waste disposal t] Food preparation 0%ilet and handwashing <br /> G H�Iot& Cold water for cleaning "Store refrigerated food ZV15otable water <br /> '$tore dry food/supplies G]A6,vernight parking QNfehicle wash <br /> I, R Zy F,-c,_ , 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 notify the EHD immediately. <br /> Signature _��,✓1�! -- Date - <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> 'P(Zo�sLt3�5 <br />