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N JOAQUIN Environmental Health Department <br /> rR -~--C O U N T Y <br /> Greatness gro,rrs here: <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 1 and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> [ 1. To be completed by APPLICANT <br /> Business Name 0 L IV eS Lic. P€ate# S Z r216 35 <br /> Owner/Operator Name 5 Q kk22 ��1� �d� �'. S y 5 t,q <br /> Business Mailing Address plV Ld <br /> city.,5MxLJM stateeA zip 9Bus. P 20 Y) 81 Alt. Ph. <br /> I, 5 0w&9 N Fir J off N � �/� ]/ hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree my approved commissary in accordance with California Heaith & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the it der must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penal"es. 1 <br /> Signature <br /> 2. To be com a ed by COMMISSARY OWNERIOP.ERATOR <br /> Commissary Name 41,6110Ai CkFL / 16 2-l'Ck CCtiTEk FA# <br /> Address l 7I 7 c U d(6,11 ST _.,._._Bus. Phone(Zo 7;5 -Sof C 6 <br /> Zip �20� Owner/Operator /1/? �f�fi'Qo <br /> Check all appropriate services provided: El" <br /> Electrical disposal IEl3-compartment sink . ElEElectrical book-ups <br /> G S lid waste disposal 1:3/f=ood preparation aToilet and handwashing <br /> IGS Hot&Cold water for cleaning Store refrigerated food L "'Potable water <br /> E Stnoree dry food/supplies 0 Overnight`=parking t Vehicle wash <br /> I -V u Cj , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,andtimeets 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 owediately. <br /> Signature _ _ _-- Date�.Z C 12- <br /> 18. <br /> To be completed by the 'ENV HEALTH 'urisdiction outside of San Joain 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 />