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SAN JOAQUIN Environmental Health Department <br /> __..—COU N T Y--_ <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility -o 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 by APPLICANT <br /> Business Name SU K A 1 Lic. Plate# rJ�6 ob <br /> Owner/Operator Name D6V1D V -TRAnJ <br /> Business Mailing Address W52a }}6100tH Tf« LI,)- <br /> City 5+15ckkOQ StateCAzip Q52o9 Bus. Ph 049) 423- X24& Alt. Ph. I�A <br /> I. DAA i D V I Rp N , 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 <br /> naand <br /> �penalties <br /> Signature ' / � Date <br /> 2. To be completed b <br /> COMMCOMMISARY OWNER/OPERATOR <br /> CommissaryName f D� I l"'PS n, /,j4 L aw shy)'7 FA# <br /> Address ZgVO �, Bus. Phone -Zo � - -�-6 / - / �6 <br /> City S�ar.&C IV4 Zip l"ZO L Owner/Operator RSl12�)b <br /> Check all appropriate services provided: <br /> N Wastewater disposal 1;'3-compartment sink Electrical hook-ups <br /> Sr Solid waste disposal 6�Food preparation .' Toilet and handwashing <br /> FX Hot& Cold water for cleaning a Store refrigerated food 50 Potable water <br /> Store dry food/supplies Overnight parking tVehicle wash <br /> -- hereby state that the information I have provided is current, true and <br /> correct'to-fliFims1of 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 Date /7 <br /> [3fo 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />