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SAN JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> r.�recrn=ss . .t r2. <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 �f I S I6ri< CL t- FCS k u«11�GL Lic. Plate# 41pl? oZ <br /> Owner/Operator Name SV) I LG tj MOScS Mf P,-rj1 eFZ <br /> Business Mailing Address_71<o1 e!�, of z6 Y11Ta Ave , 4 PT _2 � <br /> City Nf fir C4 State<n Zip'bA-;e. Bus. PhQ`1)9 6Y-?131 Alt. Ph. <br /> I, ,5 k l z-bH N.. , hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agr to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaqui my Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinue h p rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation al ' <br /> Signatur Date 5( ' p 2� <br /> 2. To be completed by COMMISSARY OWNERIO�P�ERATOR <br /> Commissary Name u(L� l 01' ! �l ti� LItK FA# <br /> Address_� 717 5. u PO I o 4 S't" Bus. Phon 2C qS> 52 <br /> Cit y,5`r)CKTC0' CA Zip �406 Owner/Operator <br /> Check all appropriate services provided: <br /> Q/Wastewater disposal b/3-compartment sink Electrical hook-ups <br /> Cl Solid waste disposal 91'/Food preparation Toilet and handwashing <br /> Or- <br /> 10�fiot& Cold water for cleaning Store refrigerated food M'Potable water <br /> f, Store dry food/supplies Overnight parking E Vehicle wash <br /> I, !\I l ! t (I C L , 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 /> commissar) o�/ner s all n�oti the EHD immediately. <br /> Signaturez!C f'^� �7 �� y 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 />