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• 4 <br /> SAN JOAVWo l FnA.,'onrrReniati Heafth Depar,rnsn-�: <br /> --COUNTY <br /> _ t.>reut ness grows !I :[;' <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> t <br /> Business NameA & JS 0+- 1091 Gtg DQaS Lic.Plate# <br /> Owner/Operator NameJD'CPtkBQfec."I &�� t AI AN }IEKNAN , (Jt75t 11 ac tudcK r A-(ftN fpm <br /> Business Mailing Address 10S SeauolA C+. 9SZoS <br /> City state � ZiP. � S Bus. Ph(Zo55°I"-6733'339te Alt. Ph. <br /> Jg <br /> BRALr- 1 K- 4 AIAO tke(tJRN064ereby 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 penalties. <br /> Date S 2 <br /> Signatur <br /> r2—. To completed bv COMMISSARY OWNER/OPERATOryR��� 11 n <br /> Commissary Name Ue Jf FA# �X\AAft r 0 <br /> Address Bus. Phone 73 ' 1 y��°'e� <br /> City-K-) Zip��OwnerlOperatoi-S�exie4alU <br /> Check all appropriate services provided: <br /> Wastewater disposal 14 3-compartment sink D Electrical hook-ups <br /> Solid waste disposal 91 Food preparation 5( Toilet and handwashing <br /> k Hot & Cold water for cleaning ), Store refrigerated food ,111�Potable water <br /> 8.5Sre dry food/ plies la Overnight parking ® Vehicle wash <br /> I, 2 , 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 c nditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ow / , -� <br /> Signature Date 4 —1^L.."-,2D21 <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. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />