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SAN 10 A Q U I N Environmental Health Department <br /> - <br /> -- COUNTY-- - <br /> . <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a 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 Vi 15 1 b iL! C-U FFCC 4.u Lt K C,,L Lic. Plate# U'5-z <br /> Owner/Operator Name S VI ( i_0 H MOSES MffKliAlcz <br /> Business Mailing Address 1161 E, Lj)D56M %� %) Ve /9 PT -z I <br /> City tateC/? Zip` 533 Bus. Ph ` t `?/✓'-I Alt. Ph. <br /> (LFA/( �, /ylr[(�,�((��� 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 671 �p2/ <br /> 2. To be completed by COMMISSARY OWNEMPERATOR <br /> CommissaryName u /Oft� "� fQ (2 AUM C&�[C_'_FA# <br /> Address 1717 s. u#01o�6 5`{- Bus. Phon !G7 -Z T 52 6 <br /> City, 7'FCKTE 6. C Zip (4�49)6 Owner/Operator K—) ( IIEkpz <br /> Check all appropriate services provided: <br /> KI/Wastewater disposal 1'3-compartment sink 10Electrical hook-ups <br /> Solid waste disposal L°IFood preparation C) Toilet and handwashing <br /> 0-fiot& Cold water for cleaning r'Store refrigerated food a Potable water <br /> a Store dry f000dd//supplies`l n Overnight parking Vehicle wash <br /> x �l 1l 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 o er s a noti the EHD immediately. / <br /> Signature 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 />