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v `uta`i`ui ly EWronlmental Health Department <br /> CCIUNTY <br /> Y <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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�lq CO S 11-LAAJz 4 A I'WW!/E 2 Lic. Plate# y T/T575 SS <br /> Owner/Operator Name1,11"1'4 t MEL&Y r-H A UE z <br /> Business Mailing Address 3 f b E RiAell sane ST, <br /> City�ock-(c) State Cf Zip S.2°S Bus. PtCcjv ) 3?3�5l�1 Alt. Ph. <br /> I,Aft ip f.SPEC ql e"11—W VE Z- , 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 penalties. <br /> Signature ,� C� 1�i1 V2 Date 5/2 y/2/ <br /> 2. To be completed by COMMISSARY OWNEWOPERATOR <br /> Commissary Name"/l�sb� (.'t4T'Alrl G %ttt(ck CL rJ�« FA1# <br /> Address/7/-7 S. ualiv.V 57. Bus. Phone(J-!E1 A�7-5YIrb <br /> Cit)S fr cero-4. c.k Zip g5a o 6 Owner/Operator ¢k7- �RAb o <br /> Check all appropriate services provided: <br /> j3-Wastewater disposal [r3-compartment sink EY Electrical hook-ups <br /> U-Solid waste disposal C3'17ood preparation CI Toilet and handwashing <br /> Ed-Hot&Cold water for cleaning EY-Store refrigerated food U-Potable water <br /> El'-store dry food/supplies l310vernight parking 13 Vehicle wash <br /> 1, AT r I f r2 AD U ' 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 modified or cancelled, the <br /> commissary ow/ner shall the EHD immediately. <br /> Signature ll/� Date .5 /2 /z / <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 /> RENS Signatu C, !{i�� Date121) /21 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />