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SAN 1UAQUIN Envi onmant�I I��;alth Dap'bilrnent <br /> —COUNTY <br /> urzctness Prows <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 1 and 2._ lfycur commissary is located outside of San Joaquin-County also complete section 3. <br /> I. To be completed by APPLICANT <br /> Business Name ,/a7.1eGA Lic.Plate# �IZ.�G✓7lJS <br /> Owner/Operator Name n- "d a 067yn <br /> Business Mailing Address Coerj S.erku,,,rz' �+ <br /> City r 11i State Glc Zip -YE7Z9 Bus. Ph. ?uy 7/z-,-1&�; Alt. Ph. <br /> I, A/w,L�nlry duv hereby state that the above information is current,true and correct to <br /> the b�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,theipermifholder-must notify the EHD. Failure to notify this-office-may-result in permit <br /> revocation and penalties. <br /> Signature Date .5 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Andress l Z!J .S Sucrr�u•!si r i Bus. Phone ZO C( Z Z 47' ;3y-s3� <br /> v <br /> City � D r Zip I r>Z 9 ' Owner/Operator <br /> Check all appropriate services provided: <br /> r�Vastewater disposal Er-3-compartment sink electrical hook-ups <br /> solid waste disposal 13 Food preparation gKoilet and handwashing <br /> MA of &Cold water for cleaning Store refrigerated food -M-15otable water <br /> Vv`S­tore dry food/supplies w6vernight parking [D Vehicle wash <br /> 'I, ' t hereby state that the information I have provided is current,true and <br /> correct c 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 owner shall notify the EHD immediately. <br /> Signature '�r�G�1�v / � Date S z 8 <br /> 3. To be completed by the ENV HEALTH 'urisdicfion outside of San Jog .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 4640138 1 www.sigov.org/ehd <br />