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SANsJOAQUIN Environmental Health Department <br />a hII- <br />fWAY'•s ---COUNTY— <br />-p P' 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 by APPLICANT / <br />Business Name P E LC a-� OR R k A S Lic. Plate # O QTS <br />Owner/Operator Name /vi 2.' )Li' h e. a <br />Business Mailing Address 4t.N.)z' ✓ iter Wo <br />Cityf �ocl fog StateMZip q�Bus. Ph._ 2a 7 410.<-.3asSAIt. Ph. <br />I, 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 aenaltles. <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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name P I C i< N q C 4 C<'_, CRCV(Y-7 FA# <br />Address rw i f i—z A V/_ Bus. Phone SL- I--• NA)r-V) ulG <br />/r Operator W <br />City STo C k 7-o/✓ Zip cA of s2®_< Owner/Operator <br />Check all appropriate services provided: n x <br />N <br />0 Wastewater disposal O 3 -compartment sink glL,211ectrical hook-ups X m Z <br />A • Gi <br />E3 Solid waste disposal O Food preparation G -Toilet and handwashing O 3 O <br />❑ Hot & Cold water for cleaning Cll,-Store refrigerated food 0 Potable water m n <br />❑ Store dry food/suppliers ®'6vemight parking 0 Vehicle wash D ;Urn <br />n <br />hereby state that the information I have provided is current, true and < <br />m <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility C m D <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the N 3 <br />commissary owner shall notify the EHD immediately.117 <br />( <br />Signature Zs Date <br />3. To be completed by the ENV HEALTH iurisdiction outside of San Joaauin 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 />