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SAN JOAQUIN Environmental Health Department <br /> OUNTY <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 com feted by APPLICANT <br /> Business Name PAIW S �(-1-5 AM Lie. Plate#71-196"o7_5- <br /> Owner/Operator <br /> 7/yg6"o75Owner/Operator NameAfyja)_l Xr—f/A <br /> Business Mailing Address 10 0 Box .6-0.3 <br /> City 2WCk_'70/V StateZip Bus. Ph.SoT -�`�OSAIt. Ph. <br /> I, 19 fyl q,_/ r 7/A , 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 penal 'i s. r q <br /> Signature l Date ��, �q <br /> Z To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name C41 C K � r, o 4 C j CRC j ro FA# <br /> Address 3y/Z C e'" /rA.'s 2 o L"h Bus. Phone <br /> City S 're CK 7an/epZip 0 S %Rr—Owner/Operator 1j\\.A 5r- l"1 Vt °! <br /> Check all appropriate services provided: —1ie 0 <br /> (3 Wastewater disposal 13 3-compartment sink � Q Electrical hook-ups n N Z <br /> E3 Solid waste disposal \E3 Food preparation Toilet and handwashing "4 111 G) <br /> 0 Hot & Cold water for cleaning �.i Store refrigerated food 13 Potable water ? Z O <br /> n <br /> Cl Store dry food/supplies Overnight parking t! Vehicle wash D X Cm's <br /> I, hereby state that the information I have provided is current, true and W > ,'p <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility N m 171 <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the 3 <br /> commissary owneer�rCCshall notify the EHD immediately. <br /> Signature ��1rr �+, �� S'c '/ 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />