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SA N.J O QQ U I N Environmental Health Department <br />---C C U N T Y— <br />Greotness grows 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 ! U R. o a%t ayD Lic. Plate # Rt 1/ 636-3 <br />Owner/Operator Name .S jl V/ lj ifS1°/d/62--i4 <br />Business Mailing Address ^? 735 ff BR LIZZ i C <br />City51br-RT-od StateLki Zip 952o & Bus. Ph4al)2(1'$493 Alt. Ph. <br />1, 6 (L V1 A c6- PrN 041 , 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 aCpepenaltief <br />Sionaturex ` Date 'Y/Co /Z a 2 ( <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName UAJI&Al C/JTERinI6 �iAck CENT6A FA,#1 <br />Address -17 i' 7 S, UN ( c nl ST- Bus. Phone <br />,%0 <br />City5TO6%CT6g Of Zip b Owner/Operator 0 <br />Check all appropriate services provided: <br />EI'Wastewater disposal 93"3 -compartment sink fElectrical hook-ups <br />Solid waste disposal ff-Food preparation UYToilet and handwashing <br />Hot & Cold water for cleaning ER'Store refrigerated food M'Potable water <br />Store dry food/suppliesC'Overnight parking Vehicle wash <br />I, f lq7— -rtRgno , 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 ownAsha)IMtify tl)e EHD immediately. / , <br />61.2°2- <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 <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 />