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S A NJ QA Q U I N Environmental Health Department <br /> ---COU N T Y---- <br /> Grcotness 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 V C'�L)'5- iti L 0 Lic. Plate#35�(�5 y"7— <br /> Owner/Operator Name ?5P adr- yljo B&I'l-G n <br /> Business Mailing Address J 7/y / <br /> Cft�CKR6 State CA Z05ZC6 Bus. Pkf -r l623`666 fAlt. Ph. <br /> I, Z G&WA 13 b 23/4 6-,--L , 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 per <br /> revocation d must n the EHD. Failure to notify this office may result in permit <br /> anpe 'es. 'ty <br /> Signature <br /> 2. To be completed by COMMISSARY OWNEWPERATOR <br /> Commissary Name U&t6d) C4-eq-p liLG 7bck el-ax eP,FA#1 <br /> Address 17/ / L!�- L1./r�t?d Bus. Phon9 . -�Z�! -� <br /> City-22LK NLI CA Zip S? Owner/Operator/iT l t O L <br /> Check all appropriate services provided: <br /> [Wastewater disposal 111/3-compartment sink 01 Electrical hook-ups <br /> Solid waste disposal [Food preparation I `foifet and handwashing <br /> a Hot & Cold water for cleaning 0-'Store refrigerated food M Potable water <br /> i <br /> Store dr�r food/su�plies Overnight parking !9 Vehicle wash <br /> I, C� 7/ 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.mod', ed or cancelled, the <br /> commissary ownerif al HD)mediately. <br /> Signature �L- / Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />