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SAN WOUIN Environmental Health Depa tman° <br /> --COUNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 1 and 2. If yourcommissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed b APPLICANT <br /> Business Name TU 1 Lic. Plate# <br /> Owner/Operator Name u i^ CC P -� J <br /> Business Mailing Address �� I <br /> City StateP Zip �SZIZBus. Ph. -�1 tP � . Ph. <br /> I, .52n G)& (JOL4 ) hereby state that the above information is current,true and correct to <br /> the best of my nowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaqu' County Environmental Health Department (EHD) requirements. if the use of the <br /> commissary is discontinu ,t permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation enalties. <br /> Signature Date (-C (l 5 lava b <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L A C-C) rAP f_C_\ f.,\ FA# <br /> Address a0IW E SAacknt, ye+�) Bus. Phone OA(A /tLl <br /> City ��U u Oxy\ Zip of S Zo 5 Owner/Operator C�'. (� A c n e_�-t <br /> Check all appropriate services provided <br /> [Wastewater disposal SI 3 compartment sink EI ncal hook-ups <br /> solid waste disposal ® Food preparation T 'let and handwashing <br /> O Hot&Cold water for cleaning 0 St refrigerated food bla water <br /> 17 Store dry food/supplies Overnight parking Vehicle wash <br /> I, , 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 con Mons of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify th D immediately. <br /> Signature Date �t�A_ -9119 A2_�' <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. 1-lazelton Avenue I Stockton,California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />